Hand eczema Coenraads, Pieter-Jan
The New England journal of medicine,
11/2012, Letnik:
367, Številka:
19
Journal Article
Recenzirano
Odprti dostop
Hand eczema is an inflammation of the skin; the cause is often multifactorial. Initial management includes avoiding causative irritants or allergens (e.g., by wearing impermeable gloves) and applying ...emollients and potent topical glucocorticoids.
Interventions for hand eczema Christoffers, Wietske Andrea; Coenraads, Pieter-Jan; Svensson, Åke ...
Cochrane database of systematic reviews,
04/2019, Letnik:
4
Journal Article
Recenzirano
Odprti dostop
Hand eczema is an inflammation of the skin of the hands that tends to run a chronic, relapsing course. This common condition is often associated with itch, social stigma, and impairment in ...employment. Many different interventions of unknown effectiveness are used to treat hand eczema.
To assess the effects of topical and systemic interventions for hand eczema in adults and children.
We searched the following up to April 2018: Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, AMED, LILACS, GREAT, and four trials registries. We checked the reference lists of included studies for further references to relevant trials.
We included randomised controlled trials (RCTs) that compared interventions for hand eczema, regardless of hand eczema type and other affected sites, versus no treatment, placebo, vehicle, or active treatments.
We used standard methodological procedures expected by Cochrane. Primary outcomes were participant- and investigator-rated good/excellent control of symptoms, and adverse events.
We included 60 RCTs, conducted in secondary care (5469 participants with mild to severe chronic hand eczema). Most participants were over 18 years old. The duration of treatment was short, generally up to four months. Only 24 studies included a follow-up period. Clinical heterogeneity in treatments and outcome measures was evident. Few studies performed head-to-head comparisons of different interventions. Risk of bias varied considerably, with only five studies at low risk in all domains. Twenty-two studies were industry-funded.Eighteen trials studied topical corticosteroids or calcineurin inhibitors; 10 studies, phototherapy; three studies, systemic immunosuppressives; and five studies, oral retinoids. Most studies compared an active intervention against no treatment, variants of the same medication, or placebo (or vehicle). Below, we present results from the main comparisons.Corticosteroid creams/ointments: when assessed 15 days after the start of treatment, clobetasol propionate 0.05% foam probably improves participant-rated control of symptoms compared to vehicle (risk ratio (RR) 2.32, 95% confidence interval (CI) 1.38 to 3.91; number needed to treat for an additional beneficial outcome (NNTB) 3, 95% CI 2 to 8; 1 study, 125 participants); the effect of clobetasol compared to vehicle for investigator-rated improvement is less clear (RR 1.43, 95% CI 0.86 to 2.40). More participants had at least one adverse event with clobetasol (11/62 versus 5/63; RR 2.24, 95% CI 0.82 to 6.06), including application site burning/pruritus. This evidence was rated as moderate certainty.When assessed 36 weeks after the start of treatment, mometasone furoate cream used thrice weekly may slightly improve investigator-rated symptom control compared to twice weekly (RR 1.23, 95% CI 0.94 to 1.61; 1 study, 72 participants) after remission is reached. Participant-rated symptoms were not measured. Some mild atrophy was reported in both groups (RR 1.76, 95% CI 0.45 to 6.83; 5/35 versus 3/37). This evidence was rated as low certainty.Irradiation with ultraviolet (UV) light: local combination ultraviolet light therapy (PUVA) may lead to improvement in investigator-rated symptom control when compared to local narrow-band UVB after 12 weeks of treatment (RR 0.50, 95% CI 0.22 to 1.16; 1 study, 60 participants). However, the 95% CI indicates that PUVA might make little or no difference. Participant-rated symptoms were not measured. Adverse events (mainly erythema) were reported by 9/30 participants in the narrow-band UVB group versus none in the PUVA group. This evidence was rated as moderate certainty.Topical calcineurin inhibitors: tacrolimus 0.1% over two weeks probably improves investigator-rated symptom control measured after three weeks compared to vehicle (14/14 tacrolimus versus 0/14 vehicle; 1 study). Participant-rated symptoms were not measured. Four of 14 people in the tacrolimus group versus zero in the vehicle group had well-tolerated application site burning/itching.A within-participant study in 16 participants compared 0.1% tacrolimus to 0.1% mometasone furoate but did not measure investigator- or participant-rated symptoms. Both treatments were well tolerated when assessed at two weeks during four weeks of treatment.Evidence from these studies was rated as moderate certainty.Oral interventions: oral cyclosporin 3 mg/kg/d probably slightly improves investigator-rated (RR 1.88, 95% CI 0.88 to 3.99; 1 study, 34 participants) or participant-rated (RR 1.25, 95% CI 0.69 to 2.27) control of symptoms compared to topical betamethasone dipropionate 0.05% after six weeks of treatment. The risk of adverse events such as dizziness was similar between groups (up to 36 weeks; RR 1.22, 95% CI 0.80 to 1.86, n = 55; 15/27 betamethasone versus 19/28 cyclosporin). The evidence was rated as moderate certainty.Alitretinoin 10 mg improves investigator-rated symptom control compared with placebo (RR 1.58, 95% CI 1.20 to 2.07; NNTB 11, 95% CI 6.3 to 26.5; 2 studies, n = 781) and alitretinoin 30 mg also improves this outcome compared with placebo (RR 2.75, 95% CI 2.20 to 3.43; NNTB 4, 95% CI 3 to 5; 2 studies, n = 1210). Similar results were found for participant-rated symptom control: alitretinoin 10 mg RR 1.73 (95% CI 1.25 to 2.40) and 30 mg RR 2.75 (95% CI 2.18 to 3.48). Evidence was rated as high certainty. The number of adverse events (including headache) probably did not differ between alitretinoin 10 mg and placebo (RR 1.01, 95% CI 0.66 to 1.55; 1 study, n = 158; moderate-certainty evidence), but the risk of headache increased with alitretinoin 30 mg (RR 3.43, 95% CI 2.45 to 4.81; 2 studies, n = 1210; high-certainty evidence). Outcomes were assessed between 48 and 72 weeks.
Most findings were from single studies with low precision, so they should be interpreted with caution. Topical corticosteroids and UV phototherapy were two of the major standard treatments, but evidence is insufficient to support one specific treatment over another. The effect of topical calcineurin inhibitors is not certain. Alitretinoin is more effective than placebo in controlling symptoms, but advantages over other treatments need evaluating.Well-designed and well-reported, long-term (more than three months), head-to-head studies comparing different treatments are needed. Consensus is required regarding the definition of hand eczema and its subtypes, and a standard severity scale should be established.The main limitation was heterogeneity between studies. Small sample size impacted our ability to detect differences between treatments.
Background
A fragrance mix consisting of eight separate fragrance ingredients (fragrance mix I FM I) is present in most baseline patch test series. Patch testing with the TRUE Test technique is ...considered to detect less contact allergy to FM I than testing with the Finn Chamber technique.
Objective
To investigate the possible significance of batch and patch test method in establishing contact allergy to FM I.
Methods
Three thousand one hundred and nineteen individuals representing a sample of the general population were patch tested with two batches of FM I with two patch test techniques at six dermatology clinics in five European countries. The TRUE Test technique and the Finn Chamber technique with pet. preparations were used. McNemar's test was used for statistical calculations.
Results
The contact allergy prevalences varied between 0.7% and 2.6%. The patch tests with the mixes containing Evernia prunastri (oak moss) with a high content of chloratranol/atranol resulted in substantially more positive reactions than the corresponding tests with the mixes containing oak moss with a low content of chloratranol/atranol. The Finn Chamber technique detected significantly more contact allergic reactions than the TRUE Test technique (P < 0.001).
Conclusion
The Finn Chamber technique detects more contact allergy to FM I than the TRUE Test technique.
Clinicians agree that hand eczema is multifactorial, although there are many uncertainties regarding causative factors. Atopic dermatitis is assumed to be a major risk factor, whereas the role of ...allergies is overestimated. Twin studies may shed light on the contribution of other endogenous, possibly genetic factors versus the role of exposure to environmental agents, with the latter being amenable to prevention and intervention.
Summary
Background
Several instruments for the assessment of the severity of hand eczema and health‐related quality of life (HR‐QoL) related to hand eczema have been developed.
Objectives
The aim of ...the present study was to evaluate the correlation between frequently used methods.
Methods
Consecutive patients with current hand eczema from three different centres participated in the study. Severity of hand eczema was assessed with the Hand Eczema Severity Index (HECSI), the Physician Global Assessment (PGA), the Clinical Photo Guide, and the Dermatology Life Quality Index (DLQI).
Results
One hundred and nineteen patients with hand eczema were included in the study. All six pairwise correlation coefficients between the tested methods were highly statistically significant. Correlation was highest between the HECSI and the PGA (r = 0.82), and weakest, although still statistically significant, between the DLQI and the other three severity scores (r between 0.30 and 0.45). Age and frequency of eruptions did not influence the correlations. With respect to sex, there was a tendency for correlation between methods to be higher for men than for women.
Conclusion
We found an overall positive correlation between the four severity assessments applied. As the weakest correlation was found between the DLQI and the other methods, it is suggested that measurement of HR‐QoL should be included for assessment of the severity and consequences of hand eczema, but the finding also indicates that a disease‐specific tool for evaluation of HR‐QoL in hand eczema patients is needed.
This is one of series of review articles on formaldehyde and formaldehyde‐releasers (others: formaldehyde in cosmetics, in clothes and in metalworking fluids and miscellaneous). Thirty‐five chemicals ...were identified as being formaldehyde‐releasers. Although a further seven are listed in the literature as formaldehyde‐releasers, data are inadequate to consider them as such beyond doubt. Several (nomenclature) mistakes and outdated information are discussed. Formaldehyde and formaldehyde allergy are reviewed: applications, exposure scenarios, legislation, patch testing problems, frequency of sensitization, relevance of positive patch test reactions, clinical pattern of allergic contact dermatitis from formaldehyde, prognosis, threshold for elicitation of allergic contact dermatitis, analytical tests to determine formaldehyde in products and frequency of exposure to formaldehyde and releasers. The frequency of contact allergy to formaldehyde is consistently higher in the USA (8–9%) than in Europe (2–3%). Patch testing with formaldehyde is problematic; the currently used 1% solution may result in both false‐positive and false‐negative (up to 40%) reactions. Determining the relevance of patch test reactions is often challenging. What concentration of formaldehyde is safe for sensitive patients remains unknown. Levels of 200–300 p.p.m. free formaldehyde in cosmetic products have been shown to induce dermatitis from short‐term use on normal skin.
Summary
Background
Penetration, autoxidation and N‐acetylation of p‐phenylenediamine (PPD) have been studied in vitro and ex vivo. However, a clear understanding of in vivo PPD penetration and the ...formation of PPD derivatives is lacking.
Objectives
To obtain insights into the in vivo penetration, clearance and formation of PPD derivatives in human skin.
Methods
Patch test chambers containing PPD 1% pet. were applied to the forearms of two human volunteers, with increasing application times. Non‐invasive Raman microspectroscopy was used for detection of PPD (derivatives) in skin at several follow‐up times.
Results
Application of a PPD 1% pet. patch for 30 min resulted in substantial amounts of PPD in the stratum corneum of 90 mg PPD/g keratin. PPD contents were highest after three applications for 1 h each (330 mg PPD/g keratin), followed by single applications for 2 h 40 min, 2 h, and 23 h. The PPD half‐time in the skin was 3 h. No spectral contributions of Bandrowski's base, monoacetyl‐PPD and diacetyl‐PPD were detected.
Conclusions
We have gained insights into the in vivo penetration of PPD in human skin by using non‐invasive Raman spectroscopy. Penetration into the skin was fast, and the PPD concentrations detected in the stratum corneum were high. PPD was detected in both the stratum corneum and the viable epidermis. Oxidized or acetylated PPD derivatives could not be detected.
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