Y. Wong

Validation of a self-administered questionnaire in Chinese in the assessment of eczema severity.

Abstract:  The purpose of this study was to validate the Chinese version of the Nottingham Eczema Severity Score (NESS) in determining the severity of atopic dermatitis (AD). Each parent or patient filled out a questionnaire in Chinese based on the NESS. A physician then repeated the NESS independently. Finally, the severity of AD was evaluated according to the Scoring Atopic Dermatitis (SCORAD) scale. The NESSs, severity grades, and SCORAD were analyzed for agreement and correlation. The severity grading agreed with the physicians grading in 38 of 52 parents (73%) and in 16 of 18 children (89%) who self‐evaluated the severity of their AD. The weighted kappa (95% confidence interval [CI]) for parents with children less than 10 years old, parents with children ≥10 years old, and patients who self‐evaluated their AD were 0.79 (0.66–0.91), 0.85 (0.69–1.00), and 0.74 (0.36–1.00), respectively. The R2 for the NESS by parents, the NESS by patients, and the SCORAD scores was 42.1%, 47.5%, and 49.8%, respectively. When compared with the parents, the older children who self‐evaluated their AD showed a better correlation of the NESS with the SCORAD index. The self‐administered questionnaire appears to be useful in assessing AD severity in Chinese children.

A survey of traditional Chinese medicine use in children with atopic dermatitis attending a paediatric dermatology clinic

Use of traditional Chinese medicine (TCM) for various paediatric diseases has been popular. Often, parents or caregivers believe that herbs possess therapeutic effects without any harmful consequence. This fallacy is especially prevalent in the caregivers of children with chronic diseases such as atopic dermatitis (AD). We interviewed 227 consecutive children with AD to assess the attitudes of the caregivers to TCM use, based on a 14‐item questionnaire. Of these respondents, 67 (30%) admitted that the child had been given TCM in the past 12 months, one‐third of these were currently taking TCM and one‐quarter had used TCM for 6 months or more. TCM was prescribed by a Chinese medicine practitioner in 63 patients (94%), and herbal tea/soup was the commonest TCM taken. The majority (94%) had not been told of any possible side effects of TCM. Nearly 60% thought that TCM helped to improve their childs AD. Respondents for children with severe eczema were less likely to think that TCM helped to improve their childs eczema than those with mild or moderate eczema. TCM use was not associated with parental ages or ‘grandparent as caregiver’ but ‘severe AD’ was an independent factor for TCM use (OR 3.24, 95% CI 1.67–6.31; p = 0.0003).

Serum levels of cutaneous T-cell attracting chemokine (CTACK) as a laboratory marker of the severity of atopic dermatitis in children

There are at least 13 scoring systems for the assessment of disease severity in atopic dermatitis (AD). Each system has its problems with interobserver and intraobserver variability. Cutaneous T‐cell attracting chemokine (CTACK) is a skin‐specific chemoattractant which may correlate with AD severity and obviate the issue of observer reliability. We evaluated whether serum CTACK concentrations were associated with the severity of AD in children according to the SCORing Atopic Dermatitis (SCORAD) index. Thirty‐seven Chinese children with AD (23 boys, 14 girls; aged 1–11 years) and 13 controls were recruited. The median (interquartile range) overall SCORAD for AD patients was 29.7 (20.3–49.7). Serum concentrations of CTACK and two other atopy‐related chemokines, macrophage‐derived chemokine (MDC) and thymus and activation‐regulated chemokine (TARC), were measured by sandwich enzyme immunoassay. There were significant correlations between SCORAD (r = 0.394, P = 0.016), its area (r = 0.528, P = 0.001) and intensity components (r = 0.429, P = 0.008) with serum levels of CTACK. The serum concentrations of inflammatory markers MDC and TARC also correlated with the CTACK concentrations (r = 0.618, P < 0.001, and r = 0.587, P = 0.001, respectively). Serum CTACK concentration appears to be a skin‐specific objective marker that correlates with various clinical and laboratory parameters of AD.

Lesson from performing SCORADs in children with atopic dermatitis: Subjective symptoms do not correlate well with disease extent or intensity

Background  Atopic dermatitis (AD) is a distressing disease associated with pruritus and sleep disturbance. It is not known how well these symptoms correlate with the extent and intensity of eczematous involvement. We evaluated whether: (i) the level of sleep loss correlates with pruritus and (ii) the level of pruritus correlates with the extent or severity of AD in children according to the SCORing Atopic Dermatitis (SCORAD) index.

A pentaherbs capsule as a treatment option for atopic dermatitis in children: An open-labeled case series

Traditional Chinese Medicine (TCM) has been used in patients with atopic dermatitis (AD), but its therapeutic effects are debatable. We evaluated the clinical and biochemical effects of a TCM capsule (PentaHerbs capsule) in children with AD. After a run-in period of 4 weeks, children old enough to manage oral medication were admitted and their disease severity was evaluated by the SCORing Atopic Dermatitis (SCORAD) index. Blood was obtained for complete blood count, total and allergen-specific immunoglobulin E (IgE), biochemical studies and inflammatory markers of AD severity [serum cutaneous T cell-attracting chemokine (CTACK), macrophage-derived chemokine (MDC), thymus and activation-regulated chemokine (TARC) and eosinophil cationic protein (ECP)] prior to, and after 3 months of, TCM use. Three PentaHerbs capsules twice a day were prescribed for 4 months. Patients were followed monthly to ensure compliance, and SCORAD scores were obtained at each visit. Five boys and four girls participated in the study. All patients had detectable food or inhalant-specific IgE in serum. There was significant improvement in the overall and component SCORAD scores. There were no significant differences between the pre- and post-treatment values of the serum CTACK, MDC, TARC and ECP levels but CTACK showed a decreasing trend (p = 0.069). No clinical or biochemical evidence of any adverse drug reaction was observed during the study period. The PentaHerbs capsules were well tolerated by the children and apparent beneficial effects were noted clinically. A larger, randomized placebo-controlled study is required to confirm the efficacy of this formulation for AD.

Skin diseases in Chinese children at a pediatric dermatology center.

Abstract:  Understanding the pattern of disease referrals is important in the delivery of a service. We followed 331 new referrals at a pediatric dermatology clinic over 12 months. Fifty percent of the patients were female; 293 patients (88.5%) had a single diagnosis and 36 (10.9%) had two diagnoses. Three leading causes for referrals accounted for 60% of the 371 skin diseases encountered: 124 diagnoses (33%) were of eczema, 73 diagnoses (20%) were of nevi, and 22 diagnoses (6%) were of viral warts. The nevi seen included melanocytic, epidermal, sebaceous, and vascular nevi. Skin biopsies were performed in 23 patients (6.9%), and microscopy and culture for fungal infections in 11 patients (3.3%). Forty‐one patients (12%) were referred to the laser clinic for assessment of their nevi or pigmented skin lesions. Topical steroids were prescribed in 47% of patients during their follow‐ups. Follow‐up appointments were offered to 90% of patients. Eczema required the most frequent follow‐up. Gender disparity in referrals was evident only in endogenous eczema (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.04–2.60 in males; p = 0.033). Girls were more likely to be referred to the laser clinic than boys (OR 2.31, 95% CI 1.10–4.92; p = 0.026). Most dermatologic diagnoses were made on clinical grounds and moderately potent topical corticosteroids were the most commonly prescribed medication. Since chronic skin disorders prevailed in the referrals, repeated follow‐up appointments were required.

A survey of bathing and showering practices in children with atopic eczema

We evaluated the emollient use and bathing habits of children with atopic eczema (AE) managed at the paediatric dermatology clinic of a university teaching hospital, using children with noneczematous skin diseases as controls. Disease severity of AE in the preceding 12 months was evaluated by the Nottingham Eczema Severity Score. Three‐quarters of patients with or without eczema preferred showering to bathing. Patients with AE were more likely to use bath oils than soap and to use emollients after a bath/shower. Review cases, however, were more likely to take a shower and for a longer time (10–30 min) than first‐visit eczema patients. These habits did not vary with season or disease severity. Emulsifying ointment was the most commonly used agent for the bath/shower. Most patients applied emollient immediately after a bath/shower. However there were still significant proportions of AE patients who used soap (40% of first‐visit vs. 27% of review cases) and who did not apply emollients after a bath/shower (25% of first‐visit vs. 23% of review cases). It is important to determine whether this problem is due to inadequate patient education or whether other factors lead to poor compliance.

Urinary leukotriene E4 correlates with severity of atopic dermatitis in children.

Leukotriene E4 (LTE4) is elevated in adults with atopic dermatitis (AD). We evaluated whether urinary LTE4 as a noninvasive marker correlates with clinical indices of disease activity in children with AD. AD patients aged 18 years or younger were eligible for inclusion in the study. Disease severity over the preceding 3 days was evaluated by the SCORing Atopic Dermatitis (SCORAD) index. Severity of AD over the past 12 months was evaluated by the Nottingham Eczema Severity Score (NESS) in Chinese. Urinary LTE4 concentration was measured by competitive enzyme immunoassay. One hundred and twenty‐six children with AD (82 boys and 44 girls) and 45 controls were recruited. The mean ± SD urinary log‐transformed LTE4 concentration in AD patients and controls was 2.94 ± 0.32 and 2.62 ± 0.20 pg/mg creatinine, respectively (P < 0.0001). SCORAD significantly correlated with NESS (r = 0.681, P < 0.0001). There were significant correlations between urinary LTE4 concentration and overall SCORAD score (r = 0.270, P = 0.002) and its extent (r = 0.185, P = 0.038) and intensity components (r = 0.247, P = 0.005), but not with NESS. When compared with mild AD, urinary LTE4 concentrations were higher in patients with moderate‐to‐severe disease (P = 0.049). Urinary LTE4 measurement is noninvasive and may be useful in supplementing the SCORAD for following longitudinal changes in AD severity in children. However, the practical value of this assay in a clinical setting remains to be determined.

Brief case series: montelukast, at doses recommended for asthma treatment, reduces disease severity and increases soluble CD14 in children with atopic dermatitis.

Background: The choice of oral therapeutic agents for the treatment of atopic dermatitis (AD) in children is limited. Montelukast, a specific cysteinyl leukotriene (LT) receptor antagonist, may be useful in alleviating AD symptoms. Objective: To evaluate the clinical and immunological effects of montelukast in children with AD. Methods: After a 2‐week run‐in, children with AD were started on oral montelukast 5 mg once‐daily for children <12 years of age and 10 mg for older children. The clinical severity of AD as indicated by the SCORing Atopic Dermatitis (SCORAD) score, and serum soluble CD14 and urinary leukotriene E4 (LTE4) concentrations were evaluated at baseline and the end of a 3‐month treatment period. Results: Four boys and three girls, with a median (range) age of 12 (3–16) years, participated in the study. The total SCORAD was reduced in five patients (by 30–84%) and remained similar in two patients. Their median (range) SCORAD scores before and after treatment were 34.7 (16.5–54.8) and 17.0 (6.9–36.9) (p = 0.046). The intensity component of SCORAD also decreased from 5 (2–10) to 3 (1–7) (p = 0.042). Serum sCD14 levels increased significantly from 5533 (4575–6452) ng/ml to 6259 (5617–8988) ng/ml (p = 0.028), whereas urinary LTE4 levels remained the same (p = 0.735). Conclusions: Montelukast, at doses recommended for asthma treatment, resulted in over 30% reduction in the total SCORAD in some children. Treatment with montelukast may also be associated with deviation of the immune system towards the Th1‐specific pathway.

Resting energy expenditure, oxygen consumption and carbon dioxide production during sleep in children with atopic dermatitis

Background: Pruritus and scratching are cardinal symptoms of atopic dermatitis (AD). Sleep and growth may also be affected in children with moderate‐to‐severe AD. We evaluated whether resting energy expenditure (REE), oxygen consumption (VO2) and carbon dioxide production (VCO2) in various stages of sleep were influenced by the disease severity. Methods: Disease severity was evaluated by the scoring atopic dermatitis (SCORAD) index. All‐night polysomnography was performed and REE, VO2 and VCO2 were measured. Results: Twenty children (13 boys and seven girls) with AD and eight controls were recruited. The median overall SCORAD for our AD patients was 36.8. The total sleep efficiency was lower in patients with severe AD than that obtained in the control group (median: 72% versus 88%; p = 0.039). When compared with mild‐to‐moderate disease (SCORAD⩽40) and controls, REE, VO2 and VCO2 in patients with severe AD (SCORAD>40) did not differ in sleep stages I and II combined, stages III and IV combined or the rapid eye movement (REM) stage. REE, VO2 and VCO2 in these sleep stages did not show significant correlation with the overall and the three components of the SCORAD scores. Conclusions: Children with AD do not appear to have significant disturbance in their resting energy consumption, oxygen consumption and carbon dioxide production during sleep. These parameters do not appear to correlate with the symptomatology of pruritus and sleep disturbance. We speculate that deranged metabolism during sleep is unlikely in children with AD.