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Stolarczyk A, Perez-Nazario N, Knowlden SA, Chinchilli E, Grier A, Paller A, Gill SR, De Benedetto A, Yoshida T, Beck LA. Bleach baths enhance skin barrier, reduce itch but do not normalize skin dysbiosis in atopic dermatitis. Arch Dermatol Res 2023; 315:2883-2892. [PMID: 37755506 PMCID: PMC10615920 DOI: 10.1007/s00403-023-02723-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/02/2023] [Accepted: 09/06/2023] [Indexed: 09/28/2023]
Abstract
Studies have demonstrated that bleach baths improve atopic dermatitis (AD) severity; however, the effects on itch, skin barrier, and cutaneous microbial composition are less clear. We examined whether bleach baths reduce itch, normalize skin barrier function, reduce S. aureus absolute abundance, and increase microbial diversity in adults with AD who were colonized with S. aureus on their non-lesional skin. This was an open label, non-randomized, controlled trial performed at a single academic center. Fifteen AD and five non-atopic healthy controls (NA) were instructed to take two bleach baths (0.005% NaClO; 5-10 min duration) per week for a total of 12 weeks as add-on therapy. Adults 18 to 65 years (inclusive) with mild to severe AD were recruited with EASI score > 6.0, S. aureus culture positivity, access to a bathtub, and ability and willingness to maintain current topical or systemic treatments. They were evaluated at baseline (before bleach baths), 6 weeks, and 12 weeks after the intervention of twice-weekly bleach baths. Efficacy measurements included EASI as well as 5-D Pruritus and ItchyQoL™. Transepidermal water loss (TEWL) and stratum corneum (SC) integrity assay were performed to assess the skin barrier. Skin dysbiosis was measured by S. aureus cultivation, S. aureus abundance (qPCR of thermonuclease gene), and V1-V3 16S rRNA gene sequencing on non-lesional and lesional AD skin. After 12 weeks of bleach baths, 8/15 (53.3%) AD subjects achieved an EASI50 and a significant reduction in itch as measured by 5-D pruritus and Itchy QoL. Eighty-seven percent reported improvements in sleep quality. At study entry, AD subjects had higher non-lesional TEWL values than NA subjects, and only AD subjects experienced a reduction with bleach baths (p = 0.006). Similarly, SC integrity improved as early as 6 weeks after bleach baths in AD subjects. Notably, bleach baths had no significant effect on S. aureus culture-positivity, qPCR absolute abundance, or microbial diversity. The addition of twice-weekly bleach baths improves investigator-assessed AD severity, patient-reported pruritus and sleep as well as physiological measures of skin barrier function in adult AD subjects while having no effect on qualitative and quantitative measures of cutaneous S. aureus. Trial Registration: ClinicalTrials.gov Identifier: NCT01996150, Date of registration: November 27th, 2013.
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Affiliation(s)
- Ania Stolarczyk
- Department of Dermatology, University of Rochester Medical Center, 601 Elmwood Ave, Box 697, Rochester, NY, 14642, USA
| | - Nelissa Perez-Nazario
- Department of Dermatology, University of Rochester Medical Center, 601 Elmwood Ave, Box 697, Rochester, NY, 14642, USA
| | - Sara A Knowlden
- Department of Dermatology, University of Rochester Medical Center, 601 Elmwood Ave, Box 697, Rochester, NY, 14642, USA
| | - Ellen Chinchilli
- Department of Dermatology, University of Rochester Medical Center, 601 Elmwood Ave, Box 697, Rochester, NY, 14642, USA
| | - Alex Grier
- University of Rochester Genomics Research Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Amy Paller
- Department of Dermatology, Northwestern University, Chicago, IL, USA
| | - Steven R Gill
- University of Rochester Genomics Research Center, University of Rochester Medical Center, Rochester, NY, USA
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, NY, USA
| | - Anna De Benedetto
- Department of Dermatology, University of Rochester Medical Center, 601 Elmwood Ave, Box 697, Rochester, NY, 14642, USA
| | - Takeshi Yoshida
- Department of Dermatology, University of Rochester Medical Center, 601 Elmwood Ave, Box 697, Rochester, NY, 14642, USA
| | - Lisa A Beck
- Department of Dermatology, University of Rochester Medical Center, 601 Elmwood Ave, Box 697, Rochester, NY, 14642, USA.
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Moran MC, Klose A, Yoshida T, De Benedetto A, Schneider LC, Ong PY, Simpson EL, Leung DYM, Miller BL, Seplaki CL, Beck LA. History of S. aureus Skin Infection Significantly Associates with History of Eczema Herpeticum in Patients with Atopic Dermatitis. Dermatol Ther (Heidelb) 2023; 13:2417-2429. [PMID: 37615834 PMCID: PMC10539263 DOI: 10.1007/s13555-023-00996-y] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 07/28/2023] [Indexed: 08/25/2023] Open
Abstract
INTRODUCTION Patients with atopic dermatitis (AD) are uniquely susceptible to a number of serious viral skin complications, including eczema herpeticum (EH), caused by herpes simplex virus. This study explored the associations between biomarkers of epithelial barrier dysfunction, type 2 immunity, Staphylococcus aureus infection, and S. aureus-specific immunoglobulin responses in a cohort of AD subjects with and without a history of EH (EH+ and EH-, respectively). METHODS A total of 112 subjects with AD (56 EH+, 56 EH-), matched by age and AD severity, were selected from a registry of over 3000 AD subjects. Logistic regression was used to test the association between history of S. aureus skin infection and history of EH, while controlling for a number of confounders. RESULTS Compared to those without a history of S. aureus skin infection, subjects with a history of S. aureus skin infection were found to have more than sixfold increased odds of having a history of EH (6.60, 95% confidence interval [CI]: 2.00-21.83), after adjusting for history of other viral skin infections (molluscum contagiosum virus, human papillomavirus), serum total IgE, and IgG against the S. aureus virulence factor SElX. CONCLUSIONS These findings indicate an important relationship between S. aureus skin infections and EH.
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Affiliation(s)
- Mary C Moran
- Department of Dermatology, University of Rochester Medical Center, Rochester, NY, USA
| | - Alanna Klose
- Department of Dermatology, University of Rochester Medical Center, Rochester, NY, USA
| | - Takeshi Yoshida
- Department of Dermatology, University of Rochester Medical Center, Rochester, NY, USA
| | - Anna De Benedetto
- Department of Dermatology, University of Rochester Medical Center, Rochester, NY, USA
| | - Lynda C Schneider
- Division of Allergy-Immunology, Department of Pediatrics, Boston Children's Hospital-Harvard Medical School, Boston, MA, USA
| | - Peck Y Ong
- Division of Clinical Immunology and Allergy, Children's Hospital Los Angeles-University of Southern California, Los Angeles, CA, USA
| | - Eric L Simpson
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | - Donald Y M Leung
- Division of Allergy-Immunology, Department of Pediatrics, National Jewish Health-University of Colorado School of Medicine, Denver, CO, USA
| | - Benjamin L Miller
- Department of Dermatology, University of Rochester Medical Center, Rochester, NY, USA
| | - Christopher L Seplaki
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Lisa A Beck
- Department of Dermatology, University of Rochester Medical Center, Rochester, NY, USA.
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Barak Levitt JA, Alemi S, Ollech A, Reiss-Huss S, Sah M, Renert-Yuval Y, Friedland R, Greenberger S, Cohen Barak E. Treatment with Methotrexate in Infants and Toddlers with Atopic Dermatitis: A Retrospective Multi-Center Study. J Clin Med 2023; 12:5409. [PMID: 37629451 PMCID: PMC10455795 DOI: 10.3390/jcm12165409] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
Atopic dermatitis (AD) is a chronic inflammatory skin disease affecting up to 20% of children. Methotrexate (MTX) is used off-label as a systemic treatment for AD patients unresponsive to topical therapies, but limited data exist regarding its safety and efficacy in children, especially in those < 4 years old. To further investigate MTX in younger patients, we screened the medical records of three referral centers between 2016 and 2022 and identified 28 infants and toddlers < 4 years old with AD treated with MTX. Mean age upon MTX initiation was 2.7 ± 1.2 years and mean investigator global assessment (IGA) score was 3.78 ± 0.4. Median duration of MTX treatment was five months. Following 12 and 24 weeks of MTX treatment, the response rate was 50% and IGA 0/1 was achieved in 14.2% and 21.4% of patients, respectively. Most treatment cessations were attributed to a lack of efficacy or parental concern. Although adverse events were reported in 57.1% of patients, MTX was discontinued due to such adverse events only in two patients (7.1%). Taken together, MTX demonstrated a high safety profile in AD patients <4 years old. MTX efficacy was moderate and presumably underestimated by parents who opted for premature treatment cessation due to concerns associated with an immunomodulatory drug.
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Affiliation(s)
| | - Sima Alemi
- Department of Dermatology, Emek Medical Center, Afula 1834111, Israel
| | - Ayelet Ollech
- Department of Dermatology, Pediatric Dermatology Service, Sheba Medical Center, Ramat-Gan 5265601, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Shiran Reiss-Huss
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Pediatric Dermatology Unit, Schneider Children’s Medical Center of Israel, Petah Tikva 4920235, Israel
| | - Mohammad Sah
- Department of Dermatology, Emek Medical Center, Afula 1834111, Israel
| | - Yael Renert-Yuval
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Pediatric Dermatology Unit, Schneider Children’s Medical Center of Israel, Petah Tikva 4920235, Israel
| | - Rivka Friedland
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Pediatric Dermatology Unit, Schneider Children’s Medical Center of Israel, Petah Tikva 4920235, Israel
| | - Shoshana Greenberger
- Department of Dermatology, Pediatric Dermatology Service, Sheba Medical Center, Ramat-Gan 5265601, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Eran Cohen Barak
- Department of Dermatology, Emek Medical Center, Afula 1834111, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa 3200003, Israel
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Chattopadhyay A, Tully J, Shan J, Sheikh S, Ohliger M, Gordon JW, Mauro T, Abuabara K. Sodium in the skin: a summary of the physiology and a scoping review of disease associations. Clin Exp Dermatol 2023; 48:733-743. [PMID: 36970766 DOI: 10.1093/ced/llad080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/16/2023] [Indexed: 07/20/2023]
Abstract
A large and growing body of research suggests that the skin plays an important role in regulating total body sodium, challenging traditional models of sodium homeostasis that focused exclusively on blood pressure and the kidney. In addition, skin sodium may help to prevent water loss and facilitate macrophage-driven antimicrobial host defence, but may also trigger immune dysregulation via upregulation of proinflammatory markers and downregulation of anti-inflammatory processes. We performed a systematic search of PubMed for published literature on skin sodium and disease outcomes and found that skin sodium concentration is increased in patients with cardiometabolic conditions including hypertension, diabetes and end-stage renal disease; autoimmune conditions including multiple sclerosis and systemic sclerosis; and dermatological conditions including atopic dermatitis, psoriasis and lipoedema. Several patient characteristics are associated with increased skin sodium concentration including older age and male sex. Animal evidence suggests that increased salt intake results in higher skin sodium levels; however, there are conflicting results from small trials in humans. Additionally, limited data suggest that pharmaceuticals such as diuretics and sodium-glucose co-transporter-2 inhibitors approved for diabetes, as well as haemodialysis may reduce skin sodium levels. In summary, emerging research supports an important role for skin sodium in physiological processes related to osmoregulation and immunity. With the advent of new noninvasive magnetic resonance imaging measurement techniques and continued research on skin sodium, it may emerge as a marker of immune-mediated disease activity or a potential therapeutic target.
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Affiliation(s)
- Aheli Chattopadhyay
- Department of Dermatology, University of California San Francisco, San Francisco, CA, USA
| | - Janell Tully
- University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Judy Shan
- Department of Dermatology, University of California San Francisco, San Francisco, CA, USA
| | - Sidra Sheikh
- Kaiser Permanente, Department of Physical Medicine & Rehabilitation, Oakland, CA, USA
| | - Michael Ohliger
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Jeremy W Gordon
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Theodora Mauro
- Department of Dermatology, University of California San Francisco, San Francisco, CA, USA
- Dermatology Service, Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Katrina Abuabara
- Department of Dermatology, University of California San Francisco, San Francisco, CA, USA
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Abstract
OBJECTIVE To assess the association of eczema with a patient's subsequent risk of death from suicide. We hypothesised that persistent eczema would be associated with an increased risk for death from suicide. DESIGN Double matched case-control study. SETTING General population of Ontario, Canada. PARTICIPANTS Patients 15-55 years old. We identified cases of suicide from coroners' reports between 1 January 1994 and 31 December 2014 and matched 1:2 with alive controls based on age, sex and socioeconomic status. EXPOSURE The primary predictor was a history of persistent eczema, defined as five or more physician visits for the diagnosis over the preceding 5 years. MAIN OUTCOME AND MEASURE Logistic regression to estimate the association between eczema and death from suicide. RESULTS We identified 18 441 cases of suicide matched to 36 882 controls over the 21-year accrual period. Persistent eczema occurred in 174 (0.94%) suicide cases and 285 (0.77%) controls yielding a 22% increased risk of suicide associated with persistent eczema (OR 1.22, 95% CI 1.01 to 1.48, p=0.037). In mediation analyses, this association was largely explained through major suicide risk factors. Two-thirds of patients with eczema who died from suicide had visited a physician in the month before their death and one in eight had visited for eczema in the month before their death. Among patients who died by suicide, jumping and poisoning were relatively more frequent mechanisms among patients with eczema. CONCLUSIONS Patients with persistent eczema have a modestly increased subsequent risk of death from suicide, but this is not independent of overall mental health and the absolute risk is low. Physicians caring for these patients have opportunities to intervene for suicide prevention.
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Affiliation(s)
- Aaron Mark Drucker
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Dermatology, Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Deva Thiruchelvam
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Donald A Redelmeier
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Evaluative Clinical Science Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Center for Leading Injury Prevention Practice Education & Research, Toronto, Ontario, Canada
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