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Polaskey MT, Bendelow A, Mukherji J, Buranosky B, Silverberg JI, Fishbein A. Facial atopic dermatitis is associated with sensitization to cow's milk, egg whites, and peanuts in children under 36 months. Pediatr Dermatol 2023; 40:497-499. [PMID: 37037213 DOI: 10.1111/pde.15326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 03/13/2023] [Indexed: 04/12/2023]
Abstract
Atopic dermatitis (AD) in early childhood often precedes the development of food sensitization and allergy, but the role of treating AD to prevent food allergy remains poorly understood. Our objective was to assess the relationship between facial dermatitis and food sensitization to cow's milk, egg whites, and peanuts in early childhood, as aggressive treatment of facial dermatitis could serve as a potential opportunity for food sensitization prevention. By 3 years of age, food sensitization levels to cow's milk, egg whites, and peanuts were 48% greater in children with facial AD than in children with no facial involvement of their AD. Additional research is needed to determine if facial involvement of AD in infants and young children is associated with increased food allergy.
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Affiliation(s)
| | - Anne Bendelow
- Ann and Robert H. Lurie Children's Hospital of Chicago, Data Analytics and Reporting, Chicago, Illinois, USA
| | - Janak Mukherji
- Division of Allergy & Immunology, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Brooke Buranosky
- Division of Allergy & Immunology, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Jonathan I Silverberg
- Department of Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Anna Fishbein
- Division of Allergy & Immunology, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Division of Allergy & Immunology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Liane JG, Morgado-Carrasco D. Dupilumab-associated Facial Erythema Successfully Treated With Oral Ivermectin. Dermatol Pract Concept 2022; 12:e2022184. [PMID: 36534505 PMCID: PMC9681168 DOI: 10.5826/dpc.1204a184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2022] [Indexed: 06/17/2023] Open
Affiliation(s)
- Javier Gil Liane
- Department of Dermatology, University of Barcelona, Hospital Clinic Barcelona, Spain
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Narla S, Silverberg JI, Simpson EL. Management of inadequate response and adverse effects to dupilumab in atopic dermatitis. J Am Acad Dermatol 2022; 86:628-636. [PMID: 34126094 DOI: 10.1016/j.jaad.2021.06.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/02/2021] [Accepted: 06/07/2021] [Indexed: 02/06/2023]
Abstract
Atopic dermatitis (AD) is a chronic inflammatory skin disease characterized by pruritus, skin pain, and sleep disturbances. Currently, dupilumab is the only systemic therapy and biologic medication approved by the United States Food and Drug Administration for moderate-to-severe AD in adults and children. There is a sparsity of literature available on determining treatment failure with dupilumab and the next steps health care providers can take to treat AD. Individual goals and quality of life and not just body surface area should be considered when defining treatment failure. Possible confounding dermatoses also should be ruled out. Early identification of dupilumab-induced adverse events is important. For most patients, dupilumab can be continued while treatment for the adverse event is initiated. Adjusting the frequency of dupilumab dosing also may be considered in some circumstances. Adjuvant therapies, such as methotrexate, azathioprine, mycophenolate mofetil, cyclosporine, or phototherapy can be added but the safety and efficacy of these combination treatments are not known at this time.
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Affiliation(s)
- Shanthi Narla
- Department of Dermatology, St. Luke's University Health Network, Easton, Pennsylvania
| | - Jonathan I Silverberg
- Department of Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Eric L Simpson
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon.
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Bruusgaard-Mouritsen MA, Garvey LH, Johansen JD. Facial contact dermatitis caused by cosmetic-relevant allergens. Contact Dermatitis 2021; 85:650-659. [PMID: 34482547 DOI: 10.1111/cod.13966] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Facial allergic contact dermatitis caused by cosmetic products is common. New allergens in cosmetics continuously emerge. OBJECTIVES To investigate characteristics of patients with facial dermatitis (FD) between 2010 and 2019 including patch test results from cosmetic-related allergens and a new test series with cosmetic-relevant natural ingredients (CRNIs). METHODS This is a retrospective study analysing demographics, clinical characteristics according to MOAHLFA index (male; occupation; atopic dermatitis; hand; leg; face; age ≥ 40 years), and patch test results to 27 cosmetic-relevant allergens in FD patients. A prospective study evaluating a screening test series with CRNIs in consecutive FD patients for 1 year was also conducted. These patients received a questionnaire for collecting extra characteristics (eg, concerning quality of life). RESULTS Of 8740 tested patients, 2292 (26.2%) had FD. Of these, 30.6% had cosmetic-induced FD. The most common cosmetic-related allergens were fragrances and preservatives. The most common patch test-positive CRNIs were hydroperoxides of limonene and linalool, and propolis. Potato and peanut were rare, but the most common prick test-positive CRNIs, however, without any relation to the use of cosmetic products. FD affected nearly all patients' quality of life and caused limitations to their daily life. CONCLUSIONS Updated management and quick diagnosis of FD is important to avoid negative impact on patients' quality of life.
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Affiliation(s)
- Maria A Bruusgaard-Mouritsen
- Department of Dermatology and Allergy, National Allergy Research Centre, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Lene H Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, Hellerup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Hellerup, Denmark
| | - Jeanne D Johansen
- Department of Dermatology and Allergy, National Allergy Research Centre, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
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Mahajan VK, Mehta KS, Chauhan PS, Sharma R, Sharma A, Verma YR, Chandel M, Sharma H, Sharma J, Singh VK, Hooda S. Clinical, Occupational and Allergological Profile of 455 Patients with Occupational Contact Dermatitis: A 5-Year Study from a Tertiary Care Center of North India. Indian Dermatol Online J 2021; 12:541-548. [PMID: 34430457 PMCID: PMC8354417 DOI: 10.4103/idoj.idoj_768_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 03/04/2021] [Accepted: 03/06/2021] [Indexed: 01/19/2023] Open
Abstract
Objectives: To evaluate clinical and occupational profile and common allergens in patients with occupational contact dermatitis (OCD). Materials and Methods: The records of 455 (M:F 2:1) patients aged 18-85 years with allergic contact dermatitis were analyzed retrospectively. The diagnosis of OCD and patterns of dermatitis were defined by standard criteria. Indian standard series comprising 20 allergens and when suspected patient's own products were patch tested by Finn chamber method as per European Society of Contact Dermatitis guidelines and relevance of positive results was defined clinically. Results: Airborne contact dermatitis (27.7%), acral dermatitis (14.1%), hand dermatitis (12.9%), acrofacial dermatitis (12.7%), and facial dermatitis (10.5%) were the common patterns. Agriculturists (51.2%), homemakers (27.9%), office workers (24.6%), and construction workers (4.6%) comprised the majority. Positive patch test results in 58% cases were from parthenium (31.7%), p-paraphenylenediamine (PPD) (22.9%), nickel (16%), fragrance mix (11%), potassium dichromate (10.7%), cobalt (7.6%), and mercaptobenzothiazole (4.9%). Hair colorants, shoe chips, and shaving cream also produced relevant positive reactions. Parthenium, PPD, fragrance mix, and potassium dichromate in agriculturists; nickel, parthenium, PPD, fragrance mix, and potassium dichromate in women, and potassium dichromate and parthenium in construction workers elicited the most positive reactions. PPD and hair colorants elicited positive reaction mainly in office workers. Conclusions: The agriculturists, homemakers, and construction workers have OCD most frequently. Parthenium in farmers, potassium dichromate in construction workers, nickel in women, and PPD in office workers were the major contact allergens. The study is limited by its retrospective design, small number of patients, and limited number of patch test allergens.
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Affiliation(s)
- Vikram K Mahajan
- Department of Dermatology, Venereology and Leprosy, Dr. Rajendra Prasad Govt. Medical College, Kangra (Tanda), Himachal Pradesh, India
| | - Karaninder Singh Mehta
- Department of Dermatology, Venereology and Leprosy, Dr. Rajendra Prasad Govt. Medical College, Kangra (Tanda), Himachal Pradesh, India
| | - Pushpinder Singh Chauhan
- Department of Dermatology, Venereology and Leprosy, Dr. Rajendra Prasad Govt. Medical College, Kangra (Tanda), Himachal Pradesh, India
| | - Reena Sharma
- Department of Dermatology, Venereology and Leprosy, Dr. Rajendra Prasad Govt. Medical College, Kangra (Tanda), Himachal Pradesh, India
| | - Anuj Sharma
- Department of Dermatology, Venereology and Leprosy, Dr. Rajendra Prasad Govt. Medical College, Kangra (Tanda), Himachal Pradesh, India
| | - Yog Raj Verma
- Department of Dermatology, Venereology and Leprosy, Dr. Rajendra Prasad Govt. Medical College, Kangra (Tanda), Himachal Pradesh, India
| | - Monika Chandel
- Department of Dermatology, Venereology and Leprosy, Dr. Rajendra Prasad Govt. Medical College, Kangra (Tanda), Himachal Pradesh, India
| | - Hitender Sharma
- Department of Dermatology, Venereology and Leprosy, Dr. Rajendra Prasad Govt. Medical College, Kangra (Tanda), Himachal Pradesh, India
| | - Jyotshna Sharma
- Department of Dermatology, Venereology and Leprosy, Dr. Rajendra Prasad Govt. Medical College, Kangra (Tanda), Himachal Pradesh, India
| | - Vijay Karan Singh
- Department of Dermatology, Venereology and Leprosy, Dr. Rajendra Prasad Govt. Medical College, Kangra (Tanda), Himachal Pradesh, India
| | - Sheenam Hooda
- Department of Dermatology, Venereology and Leprosy, Dr. Rajendra Prasad Govt. Medical College, Kangra (Tanda), Himachal Pradesh, India
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Gatica-Ortega ME, Pastor-Nieto MA. Allergic contact dermatitis to Glycyrrhiza inflata root extract in an anti-acne cosmetic product. Contact Dermatitis 2021; 85:454-455. [PMID: 33913165 DOI: 10.1111/cod.13872] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/25/2021] [Accepted: 04/26/2021] [Indexed: 11/29/2022]
Affiliation(s)
| | - María A Pastor-Nieto
- Dermatology Department, Hospital Universitario de Guadalajara, Guadalajara, Spain.,Faculty of Medicine and Health Sciences, Medicine and Medical Specialties Department, Universidad de Alcalá Alcalá de Henares, Madrid, Spain
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Mairlot M, Aerts O, Dendooven E, Herman A. Three additional cases of facial allergic contact dermatitis from the powerful pigment-lightening agent phenylethyl resorcinol. Contact Dermatitis 2021; 85:259-261. [PMID: 33745162 DOI: 10.1111/cod.13840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 03/19/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Margaux Mairlot
- Department of Dermatology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Olivier Aerts
- Department of Dermatology, University Hospital Antwerp (UZA) and Research group Immunology, Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium
| | - Ella Dendooven
- Department of Dermatology, University Hospital Antwerp (UZA) and Research group Immunology, Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium
| | - Anne Herman
- Department of Dermatology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain (UCLouvain), Brussels, Belgium
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Zhang X, Luo B, Mo H, Liao L, Wang S, Du J, Liu Q, Liang Y. Clinical Evaluation of Sequential Transdermal Delivery of Vitamin B6, Compound Glycyrrhizin, Metronidazole, and Hyaluronic Acid Using Needle-Free Liquid Jet in Facial Seborrheic Dermatitis. Front Med (Lausanne) 2020; 7:555824. [PMID: 33195305 PMCID: PMC7662080 DOI: 10.3389/fmed.2020.555824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 09/15/2020] [Indexed: 01/12/2023] Open
Abstract
Facial seborrheic dermatitis (FSD) is a common facial inflammatory dermatitis. Needle-free transdermal jet injection (NTJI) is a non-invasive injection of drug solution by using a high-pressure liquid injection instrument. To explore a safer, more tolerable, and convenient medical way using NTJI in the treatment of FSD, the patients were treated with vitamin B6, glycyrrhizin compound, metronidazole, and hyaluronic acid sequentially using NTJI every 2 weeks, and only those treated for more than three times were included. A VISIA facial imaging system for the evaluation of erythema, superficial lipid level, and roughness of skin surface and a CK analyzer for biophysical parameters, including the stratum corneum hydration, facial surface lipid, and trans-epidermal water loss, were applied. Erythema was significantly reduced after every treatment (weeks 2, 4, and 6; P < 0.05), whereas superficial lipid level was not improved significantly until week 6 (P < 0.05), and roughness of the skin surface was not improved significantly during the whole treatment. The stratum corneum hydration of lesional skin was significantly increased after three times of treatment (P < 0.05). No observable adverse effect, such as marked erythema, blistering, or atrophy, was observed. Sequential transdermal delivery of small molecular weight drugs (vitamin B6, glycyrrhizin compound, metronidazole, and hyaluronic acid) using NTJI is a safe, low-toxicity, and take-home drug-free therapy for the treatment of FSD.
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Affiliation(s)
- Xiaomin Zhang
- Department of Dermatology, Cosmetology and Venereology, Shenzhen Hospital, Southern Medical University, Shenzhen, China.,The Third School of Clinical Medicine, Southern Medical University, Shenzhen, China
| | - Bizhu Luo
- Department of Dermatology, Cosmetology and Venereology, Shenzhen Hospital, Southern Medical University, Shenzhen, China.,The Third School of Clinical Medicine, Southern Medical University, Shenzhen, China
| | - Huihui Mo
- Department of Dermatology, Cosmetology and Venereology, Shenzhen Hospital, Southern Medical University, Shenzhen, China.,The Third School of Clinical Medicine, Southern Medical University, Shenzhen, China
| | - Lexi Liao
- Department of Dermatology, Cosmetology and Venereology, Shenzhen Hospital, Southern Medical University, Shenzhen, China.,The Third School of Clinical Medicine, Southern Medical University, Shenzhen, China
| | - Shuai Wang
- Department of Dermatology, Cosmetology and Venereology, Shenzhen Hospital, Southern Medical University, Shenzhen, China.,The Third School of Clinical Medicine, Southern Medical University, Shenzhen, China
| | - Juan Du
- Department of Dermatology, Cosmetology and Venereology, Shenzhen Hospital, Southern Medical University, Shenzhen, China.,The Third School of Clinical Medicine, Southern Medical University, Shenzhen, China
| | - Qiuting Liu
- Department of Dermatology, Cosmetology and Venereology, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Yanhua Liang
- Department of Dermatology, Cosmetology and Venereology, Shenzhen Hospital, Southern Medical University, Shenzhen, China.,The Third School of Clinical Medicine, Southern Medical University, Shenzhen, China
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Boonchai W, Charoenpipatsin N, Winayanuwattikun W, Phaitoonwattanakij S, Sukakul T. Assessment of the quality of life (QoL) of patients with dermatitis and the impact of patch testing on QoL: A study of 519 patients diagnosed with dermatitis. Contact Dermatitis 2020; 83:182-188. [PMID: 32212154 DOI: 10.1111/cod.13535] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/13/2020] [Accepted: 03/22/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Dermatitis can impair the quality of life (QoL) of patients. Knowledge of the QoL-associated factors and the impact of patch testing on QoL is limited. OBJECTIVES To identify demographic and clinical factors affecting QoL, and to measure the impact of patch testing on QoL of dermatitis patients. METHODS The data and Dermatology Life Quality Index (DLQI) questionnaires of 519 dermatitis patients were analyzed. Of these, 107 underwent patch testing and completed the questionnaires two times (once before testing and again 60 days afterward). RESULTS The overall mean (±standard deviation) DLQI was 9.5 (±6.4). Patients aged 20 to 59 years and those who had more frequent disease exacerbations demonstrated significantly higher DLQIs. For each DLQI question, being female and aged 20 to 59 years were associated with impairments of various aspects of life, whereas the anatomical site of dermatitis impacted each question differently. The DLQI scores of the patients undergoing patch testing decreased significantly, irrespective of whether the test results were positive or negative. CONCLUSIONS Being of a working age and having more frequent disease exacerbations had negative QoL impacts. In addition, patch testing improved almost every aspect of the DLQI.
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Affiliation(s)
- Waranya Boonchai
- Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Norramon Charoenpipatsin
- Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | | | - Thanisorn Sukakul
- Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
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Wuyts L, van Hoof T, Lambert J, Aerts O. Allergic contact dermatitis caused by aftershave creams containing Glycyrrhiza inflata. Contact Dermatitis 2018; 77:49-51. [PMID: 28612439 DOI: 10.1111/cod.12725] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 10/03/2016] [Accepted: 10/12/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Laura Wuyts
- Department of Dermatology, University Hospital Antwerp (UZA) and University of Antwerp (UA), 2650 Antwerp, Belgium
| | - Tom van Hoof
- Department of Dermatology, University Hospital Antwerp (UZA) and University of Antwerp (UA), 2650 Antwerp, Belgium
| | - Julien Lambert
- Department of Dermatology, University Hospital Antwerp (UZA) and University of Antwerp (UA), 2650 Antwerp, Belgium
| | - Olivier Aerts
- Department of Dermatology, University Hospital Antwerp (UZA) and University of Antwerp (UA), 2650 Antwerp, Belgium
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Boonchai W, Varothai S, Winayanuwattikun W, Phaitoonvatanakij S, Chaweekulrat P, Kasemsarn P. Randomized investigator-blinded comparative study of moisturizer containing 4-t-butylcyclohexanol and licochalcone A versus 0.02% triamcinolone acetonide cream in facial dermatitis. J Cosmet Dermatol 2018; 17:1130-1135. [PMID: 29411520 DOI: 10.1111/jocd.12499] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND Facial dermatitis can result from various conditions, some of which are of a chronic and relapsing nature. The use of topical corticosteroid therapy may lead to additional adverse effects. OBJECTIVE To compare the efficacy of moisturizer containing 4-t-butylcyclohexanol, which acts as a sensitivity regulator, and licochalcone A, an anti-inflammatory agent from the licorice plant Glycyrrhiza inflata, with that of 0.02% triamcinolone acetonide (TA) for the treatment of facial dermatitis. METHODS This was a randomized, prospective, investigator-blinded study. Eighty participants with mild to moderate facial dermatitis were randomly treated with either the test facial moisturizer or 0.02% TA twice daily for the first 2 weeks. For the subsequent 2 weeks, all patients used only the test moisturizer. Clinical assessment by investigators, bioengineering measurements, patients' subjective evaluation, and clinical photography were performed at baseline, week 2, and week 4. RESULTS Both treatments showed a statistically significant improvement with regard to physician clinical assessment, skin hydration, transepidermal water loss, and patient-assessed visual analog scale after 2 and 4 weeks of treatment compared with baseline. The test facial moisturizer produced better skin hydration than TCS. The improvement in TEWL after 4 weeks of using the test moisturizer was comparable with 2-week treatment with 0.02% TA cream. However, subjective evaluation by patients indicated that TA more rapidly improved sensation sensitivity. CONCLUSION The test facial moisturizer was slower than 0.02% TA in improving facial dermatitis, but showed greater benefit in erythema control and skin hydration.
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Affiliation(s)
- Waranya Boonchai
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Supenya Varothai
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | | | - Pichanee Chaweekulrat
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pranee Kasemsarn
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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