The population of the city of Leicester contains, in addition to the 'native' population, a large immigrant 'Asian' community originating from the Indian subcontinent. Among referrals to our department, atopic dermatitis (AD) was 3,3 times more common in Asians. We therefore performed a study based on a cohort of consecutive births in Leicester hospitals to investigate the possible ethnic difference in prevalence and to examine possible reasons for an ethnic difference in referral pattern. Parents of 1,800 children were asked at the time of the birth to allow their child to be entered on a register. A year later, parents of a sample of 499 of these children, 158 Asian and 341 non-Asian, were invited for interview and for examination of the children. A total of 413 children were examined. The overall point prevalence of AD was 10.7% (95% confidence interval, 7.7%-13.7%). There was no significant ethnic difference. However, a history of eczema in a first degree relative was found in 14.2% of Asian subjects and 35.1% of non-Asians (P < 0.0001, chi-square test). The data suggest the increased referrals to our clinic from the Asian community may result from a lower level of familiarity with AD.
Objectives To determine whether installation of an ion-exchange water softener in the home could improve atopic eczema in children and, if so, to establish its likely cost and cost-effectiveness. Design An observer-blind, parallel-group randomised controlled trial of 12 weeks duration followed by a 4-week observational period. Eczema was assessed by research nurses blinded to intervention at baseline, 4 weeks, 12 weeks and 16 weeks. The primary outcome was analysed as intent-to-treat, using the randomised allocation rather than actual treatment received. A secondary per-protocol analysis excluded participants who failed to receive their allocated treatment and who were deemed to be protocol violators. Setting Secondary and primary care referral centres in England (UK) serving a variety of ethnic and social groups and including children living in both urban and periurban homes. Participants Three hundred and thirty-six children (aged 6 months to 16 years) with moderate/severe atopic eczema, living in homes in England supplied by hard water (≥ 200 mg/l calcium carbonate). Interventions Participants were randomised to either installation of an ion-exchange water softener plus usual eczema care (group A) for 12 weeks or usual eczema care alone (group B) for 12 weeks. This was followed by a 4-week observational period, during which water softeners were switched off/removed from group A homes and installed in group B homes. Standard procedure was to soften all water in the home, but to provide mains (hard) water at a faucet-style tap in the kitchen for drinking and cooking. Participants were therefore exposed to softened water for bathing and washing of clothes, but continued to drink mains (hard) water. Usual care was defined as any treatment that the child was currently using in order to control his or her eczema. New treatment regimens used during the trial period were documented. Main outcome measures Primary outcome was the difference between group A and group B in mean change in disease severity at 12 weeks compared with baseline, as measured using the Six Area, Six Sign Atopic Dermatitis (SASSAD) score. This is an objective severity scale completed by blinded observers (research nurses) unaware of the allocated intervention. Secondary outcomes included use of topical medications, night-time movement, patient-reported eczema severity and a number of quality of life measures. A planned subgroup analysis was conducted, based on participants with at least one mutation in the gene encoding filaggrin (a protein in the skin thought to be important for normal skin barrier function). Results Target recruitment was achieved (n = 336). The analysed population included 323 children who had complete data. The mean change in primary outcome (SASSAD) at 12 weeks was –5.0 [standard deviation (SD) 8.8] for the water softener group (group A) and –5.7 (SD 9.8) for the usual care group (group B) [mean difference 0.66, 95% confidence interval (CI) –1.37 to 2.69, p = 0.53]. The per-protocol analysis supported the main analysis, and there was no evidence that the treatment effect varied between children with and without mutations in the filaggrin gene. No between-group differences were found in the three secondary outcomes that were assessed blindly (use of topical medications; night-time movement; proportion showing reasonable, good or excellent improvement). Small, but statistically significant, differences in favour of the water softener were found in three of the secondary outcomes that were assessed by participants [Patient-Oriented Eczema Measure (POEM); well-controlled weeks (WCWs); Dermatitis Family Index (DFI)]. The results of the economic evaluation, and the uncertainty surrounding them, suggest that ion-exchange water softeners are unlikely to be a cost-effective intervention for children with atopic eczema from an NHS perspective. Conclusions Water softeners provided no additional benefit to usual care in this study population. Small, but statistically significant, differences were found in some secondary outcomes as reported by parents, but it is likely that such improvements were the result of response bias. Whether or not the wider benefits of installing a water softener in the home are sufficient to justify the purchase of a softener is something for individual householders to consider on a case-by-case basis. This trial demonstrated overwhelming demand for non-pharmacological interventions for the treatment of eczema, and this is something that should be considered when prioritising future research in the field. Trial registration Current Controlled Trials ISRCTN71423189. Funding This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 15, No. 8. See the HTA programme website for further project information.
Acute febrile neutrophilic dermatosis (Sweet's syndrome) is reported to be a marker for underlying malignancy. Much of the evidence for this is based on case reports, small series of cases and reviews of the literature. In order to clarify the association with malignancy and determine the common clinical features of Sweet's syndrome, we reviewed the case notes of patients presenting to six dermatology units in the U.K. Eighty-seven cases of histologically proven Sweet's syndrome were reviewed. Fourteen patients (16%) developed associated malignancy, predominantly haematological, two patients (2%) had a history of previous malignancy and four patients (5%) had premalignant conditions (monoclonal gammopathy, two: myelodysplasia, two). Malignancy developed up to a year after presentation with Sweet's syndrome. Patients with associated malignancy were more likely to be anaemic (P < 0.01) at presentation, had a lower mean platelet count (207 x 10(9)/L vs. 332 x 10(9)/L; P < 0.003) and were, on average, older (59 years vs. 49 years; P = 0.002). Contrary to previous reports, a greater percentage of females developed malignancy than males.
Background Bexarotene is a synthetic retinoid from the subclass of retinoids called rexinoids which selectively activate retinoid X receptors. It has activity in cutaneous T-cell lymphoma (CTCL) and has been approved by the European Medicines Agency since 1999 for treatment of the skin manifestations of advanced-stage (IIB–IVB) CTCL in adult patients refractory to at least one systemic treatment. In vivo bexarotene produces primary hypothyroidism which may be managed with thyroxine replacement. It also affects lipid metabolism, typically resulting in raised triglycerides, which requires prophylactic lipid-modification therapy. Effects on neutrophils, glucose and liver function may also occur. These side-effects are dose dependent and may be controlled with corrective therapy or dose adjustments. Objectives To produce a U.K. statement outlining a bexarotene dosing schedule and monitoring protocol to enable bexarotene prescribers to deliver bexarotene safely for optimal effect. Methods Leaders from U.K. supraregional centres produced this consensus statement after a series of meetings and a review of the literature. Results The statement outlines a bexarotene dosing schedule and monitoring protocol. This gives instructions on monitoring and treating thyroid, lipid, liver, blood count, creatine kinase, glucose and amylase abnormalities. The statement also includes algorithms for a bexarotene protocol and lipid management, which may be used in the clinical setting. Conclusion Clinical prescribing of bexarotene for patients with CTCL requires careful monitoring to allow safe administration of bexarotene at the optimal dose.
The association of lichen planus and primary biliary cirrhosis in five patients is reported. The coexistence of the two diseases is probably more than coincidental and may be due to the fact that both conditions are based on an alteration of mechanisms. There is great similarity between primary biliary cirrhosis and chronic graft-versus-host disease and a common pathogenesis for the two entities has been postulated. Since lichen planus is one of the most common manifestations of graft-versus-host disease, its association with primary biliary cirrhosis is of significance, although not unexpected.
AbstractSoap substitutes are widely prescribed in the belief that they improve symptoms in a wide range of skin disease. There is currently a lack of clinical evidence to support this belief. We report a study performed on 38 subjects suffering from atopic dermatitis, psoriasis or senile xerosis, in whom the response to emulsifying ointment BP and Wash E45 was assessed. The investigator was blinded as to the treatment allocated to each subject. Visual analogue scales were used by subjects and the investigator to assess improvement in symptoms and signs. Subjects were asked whether or not the treatment had been beneficial, and overall benefit was also assessed by the investigator on a scale of 0 to 4. Subjects were asked to grade the efficacy of the medication as a cleanser using a scale of 1 to 5. No differences in response could be demonstrated between the two preparations, although Wash E45 was found to be more effective as a cleanser. All parameters of severity of the skin condition improved during the study with both soap substitutes.
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