Graham A. Johnston

Comparison of the two most commonly used treatments for pyoderma gangrenosum:Results of the STOP GAP randomised controlled trial

Objective To determine whether ciclosporin is superior to prednisolone for the treatment of pyoderma gangrenosum, a painful, ulcerating skin disease with a poor evidence base for management. Design Multicentre, parallel group, observer blind, randomised controlled trial. Setting 39 UK hospitals, recruiting from June 2009 to November 2012. Participants 121 patients (73 women, mean age 54 years) with clinician diagnosed pyoderma gangrenosum. Clinical diagnosis was revised in nine participants after randomisation, leaving 112 participants in the analysis set (59 ciclosporin; 53 prednisolone). Intervention Oral prednisolone 0.75 mg/kg/day compared with ciclosporin 4 mg/kg/day, to a maximum dose of 75 and 400 mg/day, respectively. Main outcome measures The primary outcome was speed of healing over six weeks, captured using digital images and assessed by blinded investigators. Secondary outcomes were time to healing, global treatment response, resolution of inflammation, self reported pain, quality of life, number of treatment failures, adverse reactions, and time to recurrence. Outcomes were assessed at baseline and six weeks and when the ulcer had healed (to a maximum of six months). Results Of the 112 participants, 108 had complete primary outcome data at baseline and six weeks (57 ciclosporin; 51 prednisolone). Groups were balanced at baseline. The mean (SD) speed of healing at six weeks was −0.21 (1.00) cm2/day in the ciclosporin group compared with −0.14 (0.42) cm2/day in the prednisolone group. The adjusted mean difference showed no between group difference (0.003 cm2/day, 95% confidence interval −0.20 to 0.21; P=0.97). By six months, ulcers had healed in 28/59 (47%) participants in the ciclosporin group compared with 25/53 (47%) in the prednisolone group. In those with healed ulcers, eight (30%) receiving ciclosporin and seven (28%) receiving prednisolone had a recurrence. Adverse reactions were similar for the two groups (68% ciclosporin and 66% prednisolone), but serious adverse reactions, especially infections, were more common in the prednisolone group. Conclusion Prednisolone and ciclosporin did not differ across a range of objective and patient reported outcomes. Treatment decisions for individual patients may be guided by the different side effect profiles of the two drugs and patient preference. Trial registration Current Controlled Trials ISRCTN35898459.

The use of dietary manipulation by parents of children with atopic dermatitis.

Background  In 1989 we demonstrated that 71% of children referred to our paediatric dermatology clinic with atopic dermatitis (AD) had been subject to dietary manipulation by their parents in order to manage their disease. We have re‐examined our clinic population to determine whether the documented rise in the use of complementary therapy in children with skin disease has been accompanied by a rise in dietary manipulation.

Treatment of bullous impetigo and the staphylococcal scalded skin syndrome in infants

Impetigo is a common, superficial, bacterial infection of the skin characterized by an inflamed and infected epidermis. The rarer variant, bullous impetigo, is characterized by fragile fluid-filled vesicles and flaccid blisters and is invariably caused by pathogenic strains of Staphylococcus aureus. Bullous impetigo is at the mild end of a spectrum of blistering skin diseases caused by a staphylococcal exfoliative toxin that, at the other extreme, is represented by widespread painful blistering and superficial denudation (the staphylococcal scalded skin syndrome). In bullous impetigo, the exfoliative toxins are restricted to the area of infection, and bacteria can be cultured from the blister contents. In staphylococcal scalded skin syndrome the exfoliative toxins are spread hematogenously from a localized source causing widespread epidermal damage at distant sites. Both occur more commonly in children under 5 years of age and particularly in neonates. It is important to swab the skin for bacteriological confirmation and antibiotic sensitivities and, in the case of staphylococcal scalded skin syndrome, to identify the primary focus of infection. Topical therapy should constitute either fusidic acid (Fucidin®, Leo Pharma Ltd) as a first-line treatment, or mupirocin (Bactroban®, GlaxoSmithKline) in proven cases of bacterial resistance. First-line systemic therapy is oral or intravenous flucloxacillin (Floxapen®, GlaxoSmithKline). Nasal swabs from the patient and immediate relatives should be performed to identify asymptomatic nasal carriers of Staphylococcus aureus. In the case of outbreaks on wards and in nurseries, healthcare professionals should also be swabbed.

Contact dermatitis: Allergic and irritant

Facial contact dermatitis is frequently encountered in medical practice in both male and female patients. Identifying the underlying cause can be challenging, and the causative agent may be overlooked if it is not considered during the assessment of a patient. The two main types of contact dermatitis are irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD). The mechanisms and common causative agents vary for both ICD and ACD, but the clinical picture is often similar, particularly for chronic disease. Facial contact dermatitis can be successfully treated by avoiding the causative agent. In this review, we focus on the clinical assessment of a patient with facial contact dermatitis and the mechanisms of both ICD and ACD. Common causative agents, including emerging allergens, are discussed in detail, and suggestions are made regarding the management of patients with proven ICD or ACD of the face.

New and emerging cosmetic allergens

Human skin is exposed to a large variety of cosmetic allergens. Most allergic contact dermatitis occurs after exposure to fragrance, preservatives, and hair dyes. Such reactions can often be occult. As a result, a high index of suspicion is needed in assessing the patient with facial or cosmetic dermatitis. This contribution looks at why such a large number of chemicals are in everyday usage, at how dermatologists monitor trends in allergy to cosmetics, and at a number of new and emerging allergens to consider in the assessment of suspected cosmetic allergy.

The use of complementary medicine by patients referred to a contact dermatitis clinic

Our aim was to quantify and qualify the use of complementary medicine (CM) by patients referred to our contact dermatitis clinic in Leicester, UK. A face‐to‐face structured questionnaire study was made of 109 consecutive patients referred to the contact dermatitis clinic. 109 such questionnaires were completed. 21/109 (20%) of patients were Indo‐Asian and 86/109 (79%) white Caucasian. 33/109 (30%) had tried some form of CM to treat their skin condition. This use was higher in the Indo‐Asian group, where 13/21 (62%) had tried some form of CM. 21/33 (63%) who had used CM were happy to recommend it to other patients with skin disease, even though only 10/33 (30%) of these reported an improvement in their skin condition while using CM. The most frequently used CM treatments were herbal medicine [17/33 (51%)], Chinese herbal medicine [6/33 (18%)], traditional Indian medicine [4/33 (12%)] and aromatherapy [6/33 (18%)]. These proportions were similar in all ethnic groups. In a population of adults referred to a contact dermatitis clinic in a city‐centre teaching‐hospital dermatology department in Leicester, UK, 30% use, or intend to use, CM and this use is associated with ethnicity.

Neonatal erythema multiforme major

Summary A 25‐day‐old neonate developed an unusual eruption with bullae and marked systemic symptoms. Investigation for bacterial, viral, autoimmune and immunobullous causes did not reveal any identifiable trigger and histological examination was highly suggestive of bullous erythema multiforme. Pulmonary infiltrates were noted late in the course of the disease. Differential diagnoses included bullous impetigo, primary herpes simplex infection, immunobullous disease, neonatal lupus and erythema multiforme. This case illustrates the difficulties in diagnosing and managing an unwell child with bullae and emphasizes the need to exclude treatable underlying causes.

Current options for the treatment of impetigo in children.

Impetigo contagiosa is a common, superficial, bacterial infection of the skin characterised by an inflamed and infected epidermis caused by Staphylococcus aureus, Streptococcus pyogenes or both. The less common bullous impetigo is characterised by fragile fluid-filled vesicles and flaccid blisters, and is invariably caused by pathogenic strains of S. aureus. In bullous impetigo, exfoliative toxins are produced, although these are restricted to the area of infection and bacteria can be cultured from the blister contents. In the rare variant, staphylococcal scalded skin syndrome, the exfoliative toxins are spread haematogenously from a localised source causing widespread epidermal damage at distant sites.

Contact allergy to preservatives: ESSCA* results with the baseline series, 2009-2012.

Allergic contact dermatitis caused by biocides is common and causes significant patient morbidity.

Recommendation to test limonene hydroperoxides 0·3% and linalool hydroperoxides 1·0% in the British baseline patch test series

There is a significant rate of sensitization worldwide to the oxidized fragrance terpenes limonene and linalool. Patch testing to oxidized terpenes is not routinely carried out; the ideal patch test concentration is unknown.