Medical news on eczema by dr Daniel Wallach - January 2021
Discover the 1st scientific publication in 2021 by Dr Wallach
"Everything you ever wanted to know about atopic dermatitis"
"Therapeutic education works!"
"A simple way to improve compliance"
"Contact eczema in children
"Teenagers and their parents"
"COVID, hand washing, eczema in children"
"Hairdressers and their customers"
"Face and neck"
Everything you ever wanted to know about atopic dermatitis
Wollenberg A, et al; European Task Force on Atopic Dermatitis/EADV Eczema Task Force. ETFAD/EADV Eczema task force 2020 position paper on diagnosis and treatment of atopic dermatitis in adults and children.
J Eur Acad Dermatol Venereol 2020;34:2717-2744.
More than a review article, this 18-page, 322-reference position paper is a veritable encyclopedia chapter that will be of service to all those who wish to be fully up to date with the continuous progress made in the field of atopic dermatitis. Younger patients will appreciate the reminder of clinical forms, evaluation methods, conventional treatments and in particular the therapeutic scale, a useful guide for choosing the appropriate treatment for the severity of each case. The more experienced will read with interest the state of research on new treatments, which are numerous and whose role is not yet well defined. These are new biologics, oral and topical anti-JAKs, and other innovative topical treatments. Everyone will appreciate the glossary defining the main terms used. Even if they are employed on a daily basis (flare-up, remission, severity, intolerance, resistance, etc.), these terms need to be clearly defined so that everyone understands them perfectly. Finally, the chapters on allergy strategies, anti-infectious treatments, alternative approaches that appeal to so many patients and parents, and psychosomatic and psycho-educational aspects provide a balanced approach to these issues that are so important in practice. As I said at the beginning, this article is a real wealth of information.
Therapeutic education works!
Dufresne H et al.
Efficiency of a therapeutic patient education program in children with severe atopic dermatitis.
J Eur Acad Dermatol Venereol 2020; 34:e648-e651.
Between 2012 and 2017, 38 children and adolescents followed the therapeutic patient education (TPE) program at Necker-Enfants Malades Hospital in Paris. They were severe atopic patients, most often under systemic treatment or phototherapy, with a SCORAD greater than 60. Fourteen of them had already been hospitalized, for an average of 4 days, and school absenteeism averaged 2 days per month.
The TPE program consisted of 7 group sessions, each lasting 1.5 to 2 hours, and 6 individual sessions of 45 to 60 minutes. All aspects of AD were addressed: general knowledge, application of moisturizers, proper use of corticosteroids, adaptation of treatment according to clinical lesions, pruritus, allergies, and psychological and social problems in daily life. The evaluation of the program's efficacy was performed by answering questionnaires and by measuring clinical evolution. All knowledge was greatly improved, in all areas of the program. The individual and group TPE sessions, all very valuable, work well in different ways. In particular, the individual sessions allow for questions to be asked that one might not dare ask in public. For the group as a whole, the average SCORAD decreased by about half (median 25) and school absenteeism was also halved. The authors note that their TPE program is supported by the Eczema Foundation.
A simple way to improve compliance
Bashyam AM et al,
Framing atopic dermatitis topical medication application site discomfort as a signal of efficacy improves willingness to continue use.
J Am Acad Dermatol 2020; 83 :1773-1775.
It is common for atopic patients to experience a temporary unpleasant sensation when applying a topical medication. This may be tingling, burning, or other signs of discomfort. Often these sensations lead to discontinuation of treatment, even though their significance is not really critical. The authors of this study wanted to evaluate the influence of medical discourse on treatment discontinuation, or more precisely on the intention to discontinue treatment. They proposed a scenario to 1,039 adult atopic patients involving or not involving discomfort on application of a topical treatment, and asked them what their attitude would be in three different circumstances. First, the physician did not indicate anything in particular. Second, they warned that there could be unpleasant sensations upon application.
Third circumstance: the physician warned of such sensations, but indicated that they were a sign of treatment efficacy. The result is in line with the authors' expectations: if unpleasant signs are anticipated, and especially if they are presented as a sign of treatment efficacy and not an adverse effect or intolerance, fewer patients report wanting to discontinue the treatment. Given that compliance with topical treatments is particularly low, estimated at about one third of patients after two months, this is a simple way of improving compliance with treatments, and therefore their efficacy and patient satisfaction.
Contact eczema in children
Boonchai W, Chaiyabutr C, Charoenpipatsin N, Sukakul T.
Pediatric contact allergy: A comparative study with adults.
Contact Dermatitis 2021;84:34-40
It should be noted at the outset that the term "children" here refers to 112 patients under 18 years of age; their average age is 14.5 years, and although the minimum age is 2 years, three quarters of these children are over 13 years old. They are therefore adolescents and will be referred to as the "pediatric group" (PG). The aim of the authors is to compare this group with 680 adults, regarding the frequency of contact eczema. More precisely, to compare the positivity of patch tests between these two groups. These are Thai patients, studied between 2010 and 2019. The two groups differ in the frequency of atopy: about 60% of the patients in the pediatric group and 35% of the adults have an atopic history. 23% of the PG and 9% of the adults have atopic dermatitis lesions.
As is usually the case, it is assumed that the patch tests were proposed to explore an eczema suggestive of contact eczema. In the adult group, 57% of patients had at least one positive test, compared with 35% of the pediatric group (31% of atopic patients and 35% of non-atopic patients). Both groups were tested with the international standard battery, and the results are roughly comparable. The most frequent contact allergens, in both young and adult patients, were: nickel sulfate (12% of young patients), potassium dichromate (8%), methylisothiazolinone (7%), fragrances (fragrance mix II: 6%) and rubber accelerators (carba mix: 5.4%). The main conclusion is that the standard adult battery is well suited for young patients, who do not need a specifically pediatric allergen battery.
Teenagers and their parents
Ezzedine K, Shourick J, Merhand S, Sampogna F, Taieb C.
Perceived clinical severity of atopic dermatitis in adolescents: Comparison between patients' and parents' evaluation.
J Am Acad Dermatol 2021;84:164-165.
We know that the perception of the severity of atopic dermatitis is not exactly the same for patients and physicians. This is why some clinical scores require a medical approach (to get an objective view of erythema, papules, vesicles, etc.) while others measure patients' sensations (pruritus, pain, etc.). But is the perception of severity the same among patients and their families? Especially when these patients are adolescents, who are known to rarely agree with their parents. Using an online survey, the authors were able to recruit 399 atopic adolescent/parent pairs. The adolescents were aged 12 to 17 years, 58% were boys. 67% of the participating parents were mothers
The severity of atopic dermatitis was assessed by the adolescents themselves, on a three-stage overall rating scale (mild-moderate-severe). The parents evaluated their child's eczema with the same scale, and also according to the POEM score, also subjective but more detailed (pruritus, sleep disorders, bleeding, fissures, dryness, etc.). The level of concordance between adolescents and parents can be described as average. With the same overall scale, parents underestimated the severity of AD in 12% of cases and overestimated it in 6% of cases. If POEM is used by parents, the discordance is even greater, with 37% underestimating the adolescent's perception. Therefore, when an adolescent finds his or her eczema severe, only 50 to 80% of parents (depending on the scale used) agree. It is up to each family to draw the consequences, but the suffering of atopic adolescents should certainly not be underestimated.
COVID, hand washing, eczema in children
Simonsen AB et al.
High incidence of hand eczema in Danish schoolchildren following intensive hand hygiene during the COVID-19 pandemic: a nationwide questionnaire study.
Br J Dermatol. 2020;183:975-976.
When Danish children returned to school in April 2020 after the first lockdown, they were asked to wash their hands very frequently, at least once every two hours, including upon arrival at school, before and after meals, after going to the toilet, coughing, etc. and they certainly followed these instructions well. An online questionnaire was submitted to the parents of all Danish children between 5 and 13 years of age, to which about 10% responded, a total of 32,038 responses collected. The aim was to assess the incidence of hand eczema. 17.5% of the children had a previous diagnosis of atopic dermatitis. 6.5% of the children had eczema before the lockdown, and an additional 7.6% had eczema during the lockdown. Therefore, by the time schools reopened on April 15, 2020, 14.1% of children had hand eczema. The questionnaires were completed during the week following April 28, so after about 20 days of intensive hand washing. At that time, 50.5% of the children had hand eczema, most likely irritant dermatitis due to the frequent use of personal hygiene products (up to 20 times a day for some). In 62% of cases, the eczema appeared in less than three days. The risk factors identified were mainly the existence of atopic dermatitis, young age, as well as being female and the frequency of washing (two associated factors, girls being more assiduous than boys). It therefore seems important to combine hand washing recommendations with advice on how to prevent irritant dermatitis, which is known to become chronic. Finally, the authors note that the effect this hand washing had on coronavirus transmission is unknown.
Hairdressers and their customers
Piapan L, Mauro M, Martinuzzo C, Larese Filon F.
Characteristics and incidence of contact dermatitis among hairdressers in north-eastern Italy.
Contact Dermatitis 2020;83:458-465.
Gregoriou S, et al.
Occupational and non-occupational allergic contact dermatitis to hair dyes in Greece. A 10-year retrospective study.
Contact Dermatitis 2020;83:277-285.
We may start by noting that it is mainly women that are concerned here as 90% of professionals and customers affected are women. Hairdressers are at very high risk of professional eczema. They are prone to irritant dermatitis, due to contact with detergents and working with wet hands. And above all, hairdressers are in contact with many allergenic chemical products: dyes, perm liquids, hair straightening products, shampoos, hygiene and toiletry products. They also handle cleaning products. Finally, protective gloves can also be allergenic. Most often, occupational dermatitis starts at the beginning of activity, or even during apprenticeship and is a major cause of change of profession. A study conducted in the north-eastern Italy shows that although the incidence of occupational eczema has decreased in recent years, it remains high. The main sites are the hands and forearms, and also the face (airborne allergens, hand contact). The main allergens involved are p-phenylenediamine (dye product), thiuram mix (rubber gloves), ammonium persulfate, toluene-2,5 diamine and para-aminobenzene. In addition, like the rest of the population, hairdressers are frequently sensitized to nickel. Protective measures are therefore essential, right from the start of apprenticeship, but we know that they are difficult to apply rigorously.
A Greek study shows that customers of hairdressers can also suffer from contact eczema to products used in hairdressing. Contact tests show that the same allergens are responsible. In this study, of course, it is the scalp that is affected.
Face and neck
Guglielmo A, Sechi A, Patrizi A, Gurioli C, Neri I.
Head and neck dermatitis, a subtype of atopic dermatitis induced by Malassezia spp: Clinical aspects and treatment outcomes in adolescent and adult patients.
Pediatr Dermatol 2021 ; publié en ligne le 6 Novembre 2020.
Waldman RA, DeWane ME, Sloan B, Grant-Kels JM.
Characterizing dupilumab facial redness: a multi-institution retrospective medical record review.
J Am Acad Dermatol 2020;82:230-232.
Head and neck dermatitis is a variant of atopic dermatitis whose significance is debated. It is rare in children, but relatively common in adolescents and adults. The study by Guglielmo et al., although published in Pediatric Dermatology, involved 14 adults and 17 adolescents. It shows that there are several clinical varieties of HND: in adolescents, atopic history is constant and eczema is limited to the face, neck and upper torso. In adults, lesions on the rest of the body coexist and in 8 cases out of 14, there was no history of atopic dermatitis. The responsibility of Malassezias is strongly suspected, although seborrheic areas are most often spared. In any case, the only topical treatment with anti-inflammatory drugs (corticosteroids or calcineurin inhibitors) was ineffective, and the patients also received oral itraconazole, with good results in the majority of cases. It is instructive to link this HND to post-dupilumab facial redness, which was reported by Waldman et al. in 10% of treated patients. Here, topical antifungal treatment was effective.
Eczema School First Atopic Dermatitis therapeutic workshop for nurses and patients in Taiwan
21 March 2021 - In collaboration with Chung Shan Medical University Hospital, the leading medical center in Taiwan, Pierre Fabre Eczema Foundation held the first initiative in Taiwan for the Eczema School program - a comprehensive therapeutic workshop for nurses and patients.
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