Flora B. de Waard-van der Spek

The proactive wet-wrap method with diluted corticosteroids versus emollients in children with atopic dermatitis: A prospective, randomized, double-blind, placebo-controlled trial

BACKGROUND Wet-wrap treatment (WWT) has been advocated as a relatively effective treatment in children with severe atopic dermatitis (AD). WWT often serves as crisis intervention for AD. OBJECTIVES We sought to evaluate the use of WWT with diluted corticosteroids in comparison with emollient in children with severe AD during 4 weeks in a proactive schedule during which the frequency of corticosteroid applications was tapered. METHODS A randomized, double-blind, placebo-controlled study was performed in children aged 6 months to 10 years with severe AD (objective SCORAD at least 40 ± 5), comparing WWT with diluted corticosteroids (1:3 mometasone furoate 0.1% ointment and for the face 1:19 mometasone furoate 0.1% ointment under a mask) with emollient (petrolatum 20% in cetomacrogol cream). The primary outcome was improvement of the objective SCORAD; secondary outcomes included Patient-Oriented Eczema Measure and quality-of-life index. RESULTS WWT with diluted corticosteroids acted faster and was more efficacious than WWT with emollients. Best results were obtained in age groups 6 to 9 years and 0 to 3 years. The difference in efficacy evaluated by objective SCORAD was significant at all measuring points. This also applied to the quality-of-life index. LIMITATIONS The study group was relatively small. CONCLUSIONS WWT for severe AD is an effective therapy option for at least a period of 4 weeks.

Treatment of molluscum contagiosum using a lidocaine/prilocaine cream (EMLA) for analgesia

Eighty-three 4- to 12-year-old children, scheduled for curettage of at least five molluscum contagiosum lesions, participated in a double-blind study. The children were randomly allocated to receive lidocaine/prilocaine (EMLA) cream (n = 58) or placebo cream (n = 25), applied 15, 30, or 60 minutes before treatment. The pain was assessed by the children and the physician as none, slight, moderate, or severe. In addition, the children rated the pain on a visual analog scale. EMLA cream effectively prevented the pain after all three application times (p less than 0.01). No significant difference in pain was observed among the 15-, 30-, and 60-minute EMLA-treated groups, but the proportion of children reporting no pain on the verbal scale increased from 36% in the 15-minute group to 61% in the 60-minute group. In the placebo group, only one of 24 children (4%) reported no pain. Transient local redness was the only skin reaction noted. In conclusion, an application time of EMLA cream of less than 60 minutes is satisfactory for the curettage of molluscum contagiosum in children.

Allergic contact dermatitis in children: which factors are relevant? (review of the literature)

Allergic Contact Dermatitis (ACD) in children is increasing. Sensitization to contact allergens can start in early infancy. The epidermal barrier is crucial for the development of sensitization and elicitation of ACD. Factors that may influence the onset of sensitization in children are atopic dermatitis, skin barrier defects and intense or repetitive contact with allergens. Topical treatment of ACD is associated with cutaneous sensitization, although the prevalence is not high. ACD because of haptens in shoes or shin guards should be considered in cases of persistent foot eruptions or sharply defined dermatitis on the lower legs. Clinical polymorphism of contact dermatitis to clothing may cause difficulties in diagnosing textile dermatitis. Toys are another potentially source of hapten exposure in children, especially from toy‐cosmetic products such as perfumes, lipstick and eye shadow. The most frequent contact allergens in children are metals, fragrances, preservatives, neomycin, rubber chemicals and more recently also colourings. It is very important to remember that ACD in young children is not rare, and should always be considered when children with recalcitrant eczema are encountered. Children should be patch‐tested with a selection of allergens having the highest proportion of positive, relevant patch test reactions. The allergen exposure pattern differs between age groups and adolescents may also be exposed to occupational allergens. The purpose of this review is to alert the paediatrician and dermatologist of the frequency of ACD in young children and of the importance of performing patch tests in every case of chronic recurrent or therapy‐resistant eczema in children.

Atopic dermatitis: review 2000 to January 2001.

A review on atopic dermatitis is given, considering as basic information articles published over the period of February 1, 2000 to January 31, 2001. Atopic dermatitis is a chronic, inflammatory, primarily genetic-determined skin disease of which the cause is unknown. Its prevalence is rising in the industrialized countries, and no one knows why. The hygienic theory is most promising. Although most cases of atopic dermatitis are mild, the disease may be severe and widespread, with much impact on morbidity and social life. Mild cases usually clear and compromise 60% of the cases. Atopic dermatitis may always turn back. The clinical features are age related. Recently, a new subgroup was noted by several dermatologists in different parts of the world, consisting of people who suffer from atopic dermatitis for the first time at adult age. Food allergy, intolerance, and diet are still controversial and play a role especially in children until the age of 5 years. Diagnostic tests, such as the Atopy Patch Test, using food allergens, adds 10% or more positives and imitates the late-phase clinical manifestations. The Atopy Patch Test is still experimental as a diagnostic tool and has shortcomings, like difficulty in reading. Financial costs of treating and caring for atopic dermatitis may be high, stressing the importance of health care.

EAACI position paper for practical patch testing in allergic contact dermatitis in children

Allergic contact dermatitis (ACD) in children appears to be on the increase, and contact sensitization may already begin in infancy. The diagnosis of contact dermatitis requires a careful evaluation of a patients clinical history, physical examination, and skin testing. Patch testing is the gold standard diagnostic test.

Tumour necrosis factor (TNF)-blocking agents in juvenile psoriatic arthritis: Are they effective?

Objectives To evaluate the effectiveness of tumour necrosis factor (TNF) blockers in juvenile psoriatic arthritis (JPsA). Methods The study was a prospective ongoing multicentre, observational study of all Dutch juvenile idiopathic arthritis (JIA) patients using biologicals. The response of arthritis was assessed by American College of Rheumatology (ACR) paediatric response and Wallace inactive disease criteria. The response of psoriatic skin lesions was scored by a 5-point scale. Results Eighteen JPsA patients (72% female, median age onset 11.1 (range 3.3–14.6) years, 50% psoriatic skin lesions, 39% nail pitting, 22% dactylitis) were studied. The median follow-up time since starting anti-TNFα was 26 (range 3–62) months. Seventeen patients started on etanercept and one started on adalimumab. After 3 months of treatment 83% of the patients achieved ACR30 response, increasing to 100% after 15 months. Inactive disease reached in 67% after 39 months. There was no discontinuation because of inefficacy. Six patients discontinued treatment after a good clinical response. However, five patients flared and restarted treatment, all with a good response. During treatment four patients (two JPsA and two JIA patients with other subtypes) developed de novo psoriasis. In four of the nine patients the pre-existing psoriatic skin lesions improved. Conclusion Anti-TNFα therapy in JPsA seems effective in treating arthritis. However, in most patients the arthritis flared up after treatment discontinuation, emphasising the need to investigate optimal therapy duration. The psoriatic skin lesions did not respond well and four patients developed de novo psoriasis.

Treatment and Pain Relief of Ulcerative Hemangiomas with a Polyurethane Film

Background: Hemangiomas are the most common tumors occurring in young children. The most common complication in the growing phase of hemangioma is ulceration. Aim and Method: We report healing, pain relief and evolutive effects of a polyurethane film in 8 cases with ulcerative hemangiomas. Results: In all 8 infants, prompt pain relief and healing within 1–2 months were observed. An increased regression was also noted within 2–4 months, when the hemangiomas were in the normal proliferative phase. Conclusion: As far as the authors know, there is no explanation for the effectiveness of polyurethane film. Explanations could be the occlusive effects of the film inhibiting proliferation or the decrease in blood flow. As primary initial therapeutic approach in ulcerative hemangiomas, we advocate the application of a polyurethane film. This therapy is painless and suitable for children.

Soluble E-selectin and soluble ICAM-1 levels as markers of the activity of atopic dermatitis in children

The expression of adhesion molecules is up‐regulated in the skin of atopic dermatitis (AD) patients, and the levels of the soluble adhesion molecules sE‐selectin and sICAM‐1 have been reported to reflect the endothelial activation in the skin of AD patients. The objective of the study was to investigate the relationship between symptom score and levels of sE‐selectin, sICAM‐1 and sVCAM‐1 before and after 2 weeks of treatment. Eighteen children with an exacerbation of AD were admitted and treated with corticosteroid dilutions under occlusive wet dressings (wet‐wrap treatment). Symptom score (objective SCORAD) and levels of sE‐selectin, sICAM‐1, and sVCAM‐1 were assessed before and after 2 weeks of treatment. A significant correlation between the objective SCORAD before treatment and the level of sE‐selectin (p < 0.05), but not the level of sICAM‐1 (p = 0.7) or sVCAM‐1 (p = 0.5) was observed. The treatment resulted in a high degree of remission, which was reflected by a significant decrease in the level of sICAM‐1 (p < 0.01), whereas there was only a trend in the level of sE‐selectin to decrease (p = 0.08). The level of sE‐selectin after 2 weeks of treatment still correlated significantly with the objective SCORAD before treatment (p < 0.005). Soluble E‐selectin is a relative objective marker for the severity of AD. SCORAD is a treatment‐sensitive symptom of AD, whereas E‐selectin may be a more stable underlying systemic representation of AD.

Prilocaine/lidocaine patch as a local premedication for skin biopsy in children

BACKGROUND Prilocaine-lidocaine emulsion (EMLA) has been used successfully as a local anesthetic in patients undergoing superficial procedures. OBJECTIVE The purpose of this study was to investigate the analgesic effect of the patch as a local anesthetic for children undergoing a skin biopsy procedure. The effect on both the pain at the injection site and the pain of the biopsy was investigated. METHODS The study was randomized, double blinded, and placebo controlled. Of the 63 children randomly recruited into the study, 60 children were evaluated; the remaining three were withdrawn from the study. RESULTS The anesthetic patch was significantly more effective than the placebo patch in decreasing pain at the injection site. No significant difference in pain scores of the biopsy procedure was found between the study groups. No serious side effects were observed. CONCLUSION The anesthetic patch reduced the pain experienced by children subjected to a skin biopsy procedure.

Correlation between Objective SCORAD and Three-Item Severity Score used by physicians and Objective PO-SCORAD used by parents/patients in children with atopic dermatitis.

Background: A self-assessment rating scale (SAS) is a good tool to assess the fluctuating disease severity and quality of life (QoL) in children with atopic dermatitis (AD). The European Task Force on Atopic Dermatitis created an SAS based on the Scoring Atopic Dermatitis (SCORAD) index, called the Patient-Oriented SCORAD (PO-SCORAD). Objective: The aim of our study was to measure the correlation between alternative systems such as the Objective SCORAD, the Three-Item Severity (TIS) score and the Objective PO-SCORAD. We also investigated the correlations between the objective severity assessments and QoL. Methods: In a specialized outpatient clinic, an observational prospective study was performed with children ≤16 years with AD. Results: Seventy-five children were included. A good and significant correlation was shown between Objective SCORAD and Objective PO-SCORAD: Spearmans ρ correlation (rs) = 0.63 (p < 0.001). The correlation with QoL was moderate, but still significant (rs = 0.41-0.61, p < 0.001). Conclusion: The Objective PO-SCORAD can be used for the evaluation of fluctuating AD and correlates significantly with the Objective SCORAD and the less time-consuming TIS score.