The activities of the "Eczema Outreach Support" association
Eczema Outreach Support is a UK charity that helps the families of children with eczema.Read more
Hendricks AJ, Eichenfield LF, Shi VY.
The impact of airborne pollution on atopic dermatitis: a literature review.
Br J Dermatol 2020;183:16-23.
As industrialization progresses and as populations in developing countries adopt a more urban lifestyle, the prevalence of atopic dermatitis increases. This modern environment brings with it substantial air pollution, and a number of epidemiological and experimental studies suggest a link between pollution and atopic dermatitis, both in terms of its prevalence and the severity of symptoms.
Pollutants include fine particles, volatile organic compounds, gases from vehicle traffic and cigarette smoke. Both individually and combined, these pollutants render the skin barrier more fragile and more permeable. They also stimulate inflammatory processes, in particular by acting on the hydrocarbon receptor (AhR) and the NF-kappa B signaling pathway, which in turn triggers pruritus. Scratching then alters the epidermis. Research has also shown that air pollutants aggravate atopic dysbiosis, with an increase in staphylococcus colonization.
All forms of pollution lead to an increase in free radicals and alter the skin’s antioxidant defense system. So far, little is known about potential solutions, but action can be taken on two levels. On the one hand, we can fight to reduce pollution both as a collective (industrial activities, vehicle traffic) as well as individuals (wood- or coal-burning heating, smoking, certain construction methods, etc.). On the other hand, we can protect our skin by adopting a careful skin care regimen and by applying emollients regularly. Hope also lies in the development of active ingredients that neutralize the effects of pollution specifically by creating a physical barrier or by stimulating antioxidant defenses.
Eczema due to contact with essential oils
Sergoynne L, Mertens M, Dendooven E, Leysen J, Aerts O.
Allergic contact dermatitis, mimicking atopic dermatitis, associated with the use of essential oils in “home-made” cosmetics and aromatherapy diffusers.
Contact Dermatitis 2020;83:311-313.
A 10-year-old child with a history of atopy was suffering from a very itchy case of eczema which started on the eyelids, eventually making its way to the neck, scalp, torso and flexion creases. Topical treatments were ineffective, and the child was treated with ciclosporin, but with little effect.
In light of its predominance on the eyelids and the inefficacy of AD treatments, the possibility of contact eczema was considered and patch tests were carried out. These tests indicated a contact allergy to fragrances, more specifically to linalool, a key component of essential oils, particularly lavender. The investigation uncovered that the child was using scented hygiene and care products. Plus, the child’s mother had turned to aromatherapy with essential oils to treat asthma in the patient’s brother. Essential oil diffusers had therefore been placed all over the house. In addition, the mother was making “DIY” cosmetics with various ingredients, including lavender essential oil. The young patient was thus exposed to linalool on a number of fronts. Once this exposure was disrupted, the situation was resolved.
We can draw two conclusions from this all-too-common example. First, great caution should be taken when using essential oils and homemade cosmetics. Second, when the usual treatments fail to improve what appears to be atopic eczema, the possibility of a contact allergy must be explored.
The skin of front-line healthcare providers during the COVID-19 pandemic
Pei S, Xue Y, Zhao S, et al.
Occupational skin conditions on the front line: a survey among 484 Chinese healthcare professionals caring for COVID-19 patients. J Eur Acad
Dermatol Venereol 2020;34:e354-e357.
This topic, which we discussed in the July articles, is once again in the spotlight in view of the ongoing COVID-19 outbreak. Chinese and Swiss dermatologists conducted a detailed study of the skin lesions of 484 Chinese healthcare providers caring for COVID-19 patients in various hospital departments (resuscitation, general medicine, infectiology, etc.) in Wuhan and in 11 other provinces in China. Carrying out such a study is important in several respects: irritation dermatitis and eczema cause discomfort and may cause healthcare providers to stop their incredibly valuable work. Also, the possibility cannot be excluded that a skin lesion could provide an entry point for the virus.
Overall, 61.8% of the front-line healthcare providers complained of pruritus, in most cases mild (45.5%) or moderate (15.1%), and 73.1% had at least one skin abnormality related to their profession: erythema (38.8%), prurigo (22%) and in rare cases blisters, rhagades, papules, excoriations, and lichenification. In the interest of prevention, the researchers correlated the skin lesions with various factors. Those frequently associated with skin problems include the type of protection equipment (of which there are 3 levels of increasing efficacy), the duration of the work, and the duration for which the protection equipment was worn (masks, gloves, glasses).
The researchers concluded that dermatologists were needed to put in place measures to preserve skin integrity for healthcare providers in contact with COVID-19 patients.
Protection against irritation from N95 masks
Dong L, Yang L, Li Y, et al.
Efficacy of hydrogel patches in preventing facial skin damage caused by mask compression in fighting against coronavirus disease 2019: a short-term, self-controlled study.
J Eur Acad Dermatol Venereol 2020;34:e441-e443.
This study explored one measure that would make it easier for healthcare providers to wear protection masks when working with COVID-19 patients. Researchers tested the efficacy of hydrogels used to protect the skin in case of a wound or eschar. The gel used for this study contained sodium polyacrylate, cellulose and sodium hyaluronate. 19 front-line healthcare providers, who wore an N95 mask for more than 4 hours a day, participated in the study. A hydrogel patch was applied to the left side of the face. The right side was left untreated. The results clearly confirm the efficacy of these patches, with regard to both the clinical signs (erythema, swelling, papules) and the symptoms (pain, pruritus, burning sensations) demonstrated after 4 hours under the mask.
Overall, the clinical scores of the control side are three to four times higher than those of the side protected by the hydrogel. These fascinating results, although well documented by photographs published in the article, remain to be confirmed over longer periods of time.
The pain associated with atopic dermatitis
Huet F, Shourick J, Séité S, Taïeb C, Misery L.
Pain in Atopic Dermatitis: An Online Population-based Survey.
Acta Derm Venereol 2020;100:adv00198.
The pain experienced by patients with atopy is a highly complex issue. Previously, it was largely ignored, with pruritus being considered as the manifestation of pain in the skin and the summation of the functional symptoms of eczema. On a neurophysiological level, pain and pruritus are distinct and sometimes opposing phenomena. For example, the pain caused by intense scratching relieves pruritus. We now know that pain and pruritus are not mutually exclusive and can even coexist. As a result, the recommendation for clinical trials on atopic dermatitis and its treatments is to question the patients both on the intensity of their pruritus and on the pain they are experiencing.
This French study in which an online survey was conducted on a sample general adult population confirms just how often patients with atopic dermatitis experience pain. 5,000 people participated in the study, which relies on statements exclusively without any clinical exam. 3,247 people had no skin disease and acted as the control group; 185 (3.7%) had atopic dermatitis. 54.6% of the atopic dermatitis patients (versus 6% of the control group) reported suffering from skin pain. This pain was rated up to 6/10 and often had a neuropathic component, as had been previously demonstrated. Patients with painful AD reported significant changes in their quality of life scores. In addition, these subjects were more likely to be smokers.
Among those patients with painful AD, 11% reported constant pain throughout the day, while the rest reported intermittent pain or only pain associated with scratching. The pain was either diffuse or limited to the lesions, and was particularly intense on cracks or scratches. Theoretically, a pain score of 6/10 would justify the prescription of analgesics. One must exercise caution, however, as the pain from eczema is likely relieved significantly by treating the eczema itself, without recourse to psychotropics, the risks of which are well known.
Preventing eczema in nurses
Madan I, Parsons V, Ntani G, et al.
A behavior change package to prevent hand dermatitis in nurses working in the National Health Service: results of a cluster randomized controlled trial.
Br J Dermatol 2020;183:462-470.
Nurses are at especially high risk for dermatitis in the hands, be it irritation dermatitis or contact eczema. The consequences are evident: painful eczema, work stoppages, even a career change. Although the preventive measures are well known, they are applied inconsistently. It was probably for the purpose of convincing nurses of the merits of such measures that this large-scale controlled trial was conducted in the United Kingdom. It involved 35 hospitals and nearly 2,000 nurses (mostly women). Participants were recruited from two particularly high-risk groups: first-year students with a history of atopy, and nurses working in intensive care units. In the “control” sites, the usual measures were instituted. In the “intervention” sites, the nurses were provided information on good behaviors, in the form of a 32-page leaflet and an online version. Hydrating creams were also provided. The primary evaluation parameter was the incidence of hand dermatitis after 12 to 15 months of follow-up. The results have been deemed negative as no statistically significant difference was observed between the two groups. Nonetheless, the trend does lean in favor of the intervention group, which is a good sign. It is also worth noting that only half of the nurses who received the information actually completed the module, print or online, outlining the good behaviors, either because they forgot or had no time. Although these results are disappointing, the difficulty in proving the efficacy of such interventions should in no way dissuade efforts to promote good behaviors, hand protection, the use of disinfectants over soap, and the regular application of emollients.
Sleep disorders and atopic dermatitis
Jachiet M, Bieuvelet S, Argoud AL et al.
Sleep disturbance in atopic dermatitis: a case-control study using actigraphy and smartphone-collected questionnaires.
Br J Dermatol 2020; 183;577-579.
Sleep disorders have long been associated with atopic dermatitis as one of the most insufferable side effects of itching. They are taken into account by the SCORAD, and a number of studies have demonstrated their devastating impact on quality of life. Sleep disorders also disrupt and impede daytime activities such as learning at school, professional tasks, or the operation of a motor vehicle—with potentially serious consequences. For this reason, an accurate assessment on the impact of sleep disorders is essential to understanding the severity of AD and its impact on daily life. A team from the Saint-Louis hospital in Paris had participants complete a questionnaire via a smartphone app. The results show a strong correlation with those obtained through actigraphy, a method used by sleep clinicians to record nocturnal motor activity.
The data collected from 15 adults with atopy were compared to those of 18 healthy volunteers. The results confirm that, among those with atopy (average EASI score of 21), all the sleep parameters are pathological: total duration of sleep, time required to fall asleep, night wakings. Insofar as actigraphy is not common practice, this study supports the use of the questionnaire as a simple self-evaluation of sleep quality as well as a means of measuring changes in results over the course of treatment.
Clinical performance of JAK inhibitors
Simpson EL, Lacour JP, Spelman L, et al.
Baricitinib in patients with moderate-to-severe atopic dermatitis and inadequate response to topical corticosteroids: results from two randomized monotherapy phase III trials.
Br J Dermatol 2020;183:242-255. Simpson EL, Sinclair R, Forman S, et al.
Efficacy and safety of abrocitinib in adults and adolescents with moderate-to-severe atopic dermatitis (JADE MONO-1): a multicentre, double-blind, randomised, placebo-controlled, phase 3 trial. Lancet 2020;396:255-266. If you are a regular reader of Medical News on Eczema, then you are already aware that several pharmaceutical firms are working on developing a whole new therapeutic class of medications: JAK, or Janus kinase, inhibitors. By blocking the action of these enzymes, JAK inhibitors neutralize the effects of inflammatory cytokines at the intra-cellular level. These JAK inhibitors are available in oral or topical formulas, and several very promising results from preliminary clinical trials have been published.
Research has now progressed to phase 3 trials, which should soon make these medications available for the treatment of severe cases of atopic dermatitis. The two articles cited here have many points in common. They share the same lead author, Prof. Eric Simpson (Portland, USA), and were conducted in a number of specialist centers in Europe, Asia and North America. They share the same goal: to demonstrate greater efficacy than the placebo and good tolerance, both criteria required by the government agencies responsible for market authorization. Baricitinib (Lilly Laboratories) is a JAK1 and JAK2 inhibitor.
The clinical trials BREEZE-AD1 and BREEZE AD-2 each recruited more than 600 adult patients presenting with severe AD unimproved by topical treatments. Over the course of 16 weeks, the patients administered a daily dose of either a placebo or baricitinib (1 mg, 2 mg or 4 mg). They were asked to apply emollients, but topical corticosteroids were prohibited. Several evaluation criteria were measured: overall satisfaction (IGA), EASI scores, POEM, pruritus scores, and pain scores. The efficacy of baricitinib is dose-dependent, and the daily doses of 2 mg and particularly 4 mg provided greater efficacy than the placebo. To cite but one figure, approximately 25% of the patients achieved an EASI-75 score at 16 weeks. Abrocitinib (Pfizer Laboratories) is a JAK1 inhibitor. The phase 3 trial dubbed JADE-MONO-1 recruited nearly 400 patients with severe, stubborn AD (including 20% adolescents between the ages of 12 and 18 years, and 80% adults). The study compared daily oral doses of the medication (100 mg and 200 mg) with a placebo over the course of 12 weeks. Once again, the AD clinical trial followed a strict methodology, and several clinical criteria were measured (overall scores, pruritus, quality of life).
Here, we will note only the EASI-75 response rate, as it is currently impossible to compare the results of this trial with those of baricitinib, dupilumab or any other treatments, so long as a direct comparison has not been done. The percentage of patients who achieved EASI-75 at 12 weeks was 40% for the 100 mg dose and 63% for the 200 mg dose. At their current stage of development, it is fair to say that oral JAK inhibitors are effective. They have a good tolerance, without any particular concerns so far. We know, however, that preliminary clinical trials sometimes fail to uncover all the potential side effects. It seems that patients suffering from severe atopic dermatitis will soon have access to new systemic treatments.
Eczema Outreach Support is a UK charity that helps the families of children with eczema.Read more
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