Arnold P. Oranje

Clinical Validation and Guidelines for the SCORAD Index: Consensus Report of the European Task Force on Atopic Dermatitis

BACKGROUND We have previously reported how the SCORAD index was designed. This cumulative index combines objective (extent and intensity of lesions) and subjective (daytime pruritus and sleep loss) criteria. AIMS To study interobserver variability in scoring for objective SCORAD criteria and to optimize the scoring guidelines. MATERIAL AND METHODS Three scoring sessions were organized in 1993-1994 in Hamburg, Bordeaux and Rotterdam totalizing 19 patients (14 children and 5 adults) and 23 physicians, among whom 12 participated in at least 2 scoring sessions; 169 evaluation sheets have been processed using the SCORAD File Marker Pro software. At each session, total body photographs and close-up views were taken of each patient, and this material was reviewed at the final evaluation. RESULTS The extent of lesions according to the rule of nines showed interobserver variability mostly for patients with lesions of moderate intensity involving 20-60% of body surface. Intensity items were scored with more consistency overall, but variations subsided especially for oozing/crusts and lichenifications. Low and high scorer profiles and the benefit of training were noted. CONCLUSIONS This study has allowed to optimize clinical scoring using the SCORAD system. A proposal has been made to grade the severity of atopic dermatitis according to objective criteria in three groups for inclusion in clinical trials. The SCORAD index remains the major criterion for follow-up in trials.

Dietary prevention of allergic diseases in infants and small children.

Because of scientific fraud four trials have been excluded from the original Cochrane meta‐analysis on formulas containing hydrolyzed protein for prevention of allergy and food intolerance in infants. Unlike the conclusions of the revised Cochrane review the export group set up by the Section on Paediatrics, European Academy of Allergology and Clinical Immunology (SP‐EAACI) do not find that the exclusion of the four trials demands a change of the previous recommendations regarding primary dietary prevention of allergic diseases. Ideally, recommendations on primary dietary prevention should be based only on the results of randomized and quasi‐randomized trials (selection criteria in the Cochrane review). However, regarding breastfeeding randomization is unethical, Therefore, in the development of recommendations on dietary primary prevention, high‐quality systematic reviews of high‐quality cohort studies should be included in the evidence base. The study type combined with assessment of the methodological quality determines the level of evidence. In view of some methodological concerns in the Cochrane meta‐analysis, particularly regarding definitions and diagnostic criteria for outcome measures and inclusion of non peer‐reviewed studies/reports, a revision of the Cochrane analysis may seem warranted. Based on analysis of published peer‐reviewed observational and interventional studies the results still indicate that breastfeeding is highly recommended for all infants irrespective of atopic heredity. A dietary regimen is effective in the prevention of allergic diseases in high‐risk infants, particularly in early infancy regarding food allergy and eczema. The most effective dietary regimen is exclusively breastfeeding for at least 4–6 months or, in absence of breast milk, formulas with documented reduced allergenicity for at least the first 4 months, combined with avoidance of solid food and cows milk for the first 4 months.The role of primary prevention of allergic diseases has been a matter of debate for the last 40 years. In order to shed some light on this issue, a group of experts of the Section of Pediatrics EAACI reviewed critically the existing literature on the subject. An analysis of published peer-reviewed observational and interventional studies was performed following the statements of evidence as defined by WHO. The results of the analysis indicate that breastfeeding is highly recommended for all infants irrespective of atopic heredity. A dietary regimen is unequivocally effective in the prevention of allergic diseases in high-risk children. In these patients breastfeeding combined with avoidance of solid food and cows milk for at least 4-6 months is the most effective preventive regimen. In the absence of breast milk, formulas with documented reduced allergenicity for at least 4-6 months should be used.

The prevalence of positive reactions in the atopy patch test with aeroallergens and food allergens in subjects with atopic eczema: a European multicenter study

Background:  The atopy patch test (APT) was proposed to evaluate IgE‐mediated sensitizations in patients with atopic eczema (AE).

Juvenile versus maturity-onset alopecia areata- a comparative retrospective clinical study

We report a retrospective study of 209 patients presenting with alopecia areata (AA) at our skin department during the period 1969-1987, with special reference to possible associations, aetiological factors and the relevance of additional investigations. The patients were divided into two groups: (I) those in whom AA developed during childhood; (II) those in whom AA developed in adult life (greater than or equal to 16 years). The aim of this study was to establish whether there is a difference between juvenile and maturity-onset AA and to consider the value of additional investigations in AA. Juvenile AA is more severe and has a less favourable prognosis than the maturity-onset disease. Statistically significant differences between the two groups were not found with respect to AA type and prevalence of auto-antibodies. Bad prognostic signs in AA were early age of onset, atopy (or first-degree family history) and ophiasis and/or onychodystrophy. Initial thyroid function testing seems advisable in patients with AA. Additional valuable investigations may include hair-root examination, determination of antibodies against thyroid tissue, and serum zinc levels. There are indications that psychosomatic factors may play a role in AA. In our study, psychosomatic factors were found in 29% of the juvenile AA and in 17% of the maturity-onset AA patients.

Towards global consensus on outcome measures for atopic eczema research: results of the HOME II meeting

The use of nonstandardized and inadequately validated outcome measures in atopic eczema trials is a major obstacle to practising evidence‐based dermatology. The Harmonising Outcome Measures for Eczema (HOME) initiative is an international multiprofessional group dedicated to atopic eczema outcomes research. In June 2011, the HOME initiative conducted a consensus study involving 43 individuals from 10 countries, representing different stakeholders (patients, clinicians, methodologists, pharmaceutical industry) to determine core outcome domains for atopic eczema trials, to define quality criteria for atopic eczema outcome measures and to prioritize topics for atopic eczema outcomes research. Delegates were given evidence‐based information, followed by structured group discussion and anonymous consensus voting. Consensus was achieved to include clinical signs, symptoms, long‐term control of flares and quality of life into the core set of outcome domains for atopic eczema trials. The HOME initiative strongly recommends including and reporting these core outcome domains as primary or secondary endpoints in all future atopic eczema trials. Measures of these core outcome domains need to be valid, sensitive to change and feasible. Prioritized topics of the HOME initiative are the identification/development of the most appropriate instruments for the four core outcome domains. HOME is open to anyone with an interest in atopic eczema outcomes research.

Collodion baby: A follow-up study of 17 cases

Seventeen cases of collodion baby are reported. Clinical aspects, complications, treatment, final outcome and family history were studied. We did not observe any clinical features in the collodion baby that could serve as a clue in predicting the final diagnosis. Infections were observed in nine, hypothermia in five and hypernatraemic dehydration in four cases. Skin infection mainly occurred in babies treated with emollients (petrolatum, lanolin and cetomacrogolis cream were used). We therefore recommend treating the collodion baby in a humidified incubator, if necessary with intravenous rehydration, but not to use emollients. The final outcome of these study patients was erythrodermic autosomal recessive lamellar ichthyosis in seven cases (41%), non‐erythrodermic autosomal recessive lamellar ichthyosis in three cases (18%), Sjögren–Larsson in one case (6%), epidermolytic hyperkeratosis in one case (6%), acute neonatal variant of Gaucher disease in one case (6%) and normal skin in four cases (24%).

Trichotillomania in childhood

Several aspects of trichotillomania in childhood are described and discussed. Case records of twenty-one children not older than 15 years of age, who were seen in the previous 5 years, were examined. The female/male ratio was 2.5:1 (fifteen girls and six boys); the age range was 2 to 15 years. Although trichotillomania may, at first sight, often impress as an apparently inexplicable persistent habit, further analysis shows that this symptom often develops in a climate of psychosocial stress in the family, e.g., hospitalizations of child or mother, the additional stress inherent in moving to a new house, or developmental problems such as sibling rivalry, inability to focus activities and play in the younger child, and school problems in the older child.

Markers for early sensitization and inflammation in relation to clinical manifestations of atopic disease up to 2 years of age in 133 high‐risk children

The combination of genetic susceptibility and environmental factors induce allergic sensitization and subsequently local inflammation, resulting in atopic manifestations.

Patch Tests in Children with Suspected Allergic Contact Dermatitis: A Prospective Study and Review of the Literature

Aims: The results of patch testing in children visiting our out-patient clinic with suspected allergic contact dermatitis (ACD) were prospectively investigated and compared with those reported in the literature. A review of the literature on patch testing and ACD in children is provided. Methods: Children were patch tested using the TRUE® test, supplemented with tixocortol-17-pivalate, budesonide and 3 commonly used emollients. Supplementary patch tests were undertaken on indication. Results: Seventy-nine children (31 boys and 48 girls) were patch tested. Of the patients tested, 40 (51%) had 1 or more positive allergic patch test reactions. Twenty-two (55%) of these 40 children suffered from atopic dermatitis, 9 (23%) from hand or foot dermatitis, and 9 (23%) from other skin ailments. Nickel was the most common contact allergen, but many other common and less common allergens were noted to give positive patch tests in patients. Conclusion: Sensitization to contact allergens may begin in infancy and continue to be more common in toddlers and young children. In recalcitrant atopic dermatitis, especially at the age of 5 years and over, patch tests are indicated. Good information on preventing the development of ACD in children is useful for caregivers.

Mast cell distribution in normal adult skin

Aims: To investigate mast cell distribution in normal adult skin to provide a reference range for comparison with mastocytosis. Methods: Mast cells (MCs) were counted in uninvolved skin adjacent to basal cell carcinomas and other dermatological disorders in adults. Results: There was an uneven distribution of MCs in different body sites using the anti-tryptase monoclonal antibody technique. Numbers of MCs on the trunk, upper arm, and upper leg were similar, but were significantly different from those found on the lower leg and forearm. Two distinct groups were formed—proximal and distal. There were 77.0 MCs/mm2 at proximal body sites and 108.2 MCs/mm2 at distal sites. Adjusted for the adjacent diagnosis and age, this difference was consistent. The numbers of MCs in uninvolved skin adjacent to basal cell carcinomas and other dermatological disorders were not different from those in the control group. Differences in the numbers of MCs between the distal and the proximal body sites must be considered when MCs are counted for a reliable diagnosis of mastocytosis. A pilot study in patients with mastocytosis underlined the variation in the numbers of MCs in mastocytosis and normal skin, but showed a considerable overlap. The observed numbers of MCs in adults cannot be extrapolated to children. Conclusions: MC numbers varied significantly between proximal and distal body sites and these differences must be considered when MCs are counted for a reliable diagnosis of mastocytosis. There was a considerable overlap between the numbers of MCs in mastocytosis and normal skin.