Background: Evidence-based treatment algorithms, successfully established for asthma, are missing for atopic eczema (AE). Objectives: To investigate whether treatment according to an evidence-based algorithm is an effective and applicable concept for the management of AE. Methods: Based on a systematic literature review, we developed an evidence-based severity-score-oriented treatment algorithm for AE and compared its effectiveness to that of an individualised symptom-oriented treatment (individual therapy) in a randomised controlled trial. Sixty-three participants were randomised to algorithm (n = 32) or individual therapy (n = 31) and treated accordingly for 12 months. Study end points included difference between baseline SCORAD and mean SCORAD under treatment (primary end point), quality of life and treatment utilisation. Analysis was by intention to treat (registration: ClinicalTrials.gov:NCT00148746). Results: No statistically significant differences in clinical or subjective response were observed between groups. Treatment following the algorithm and individual treatment both effectively controlled AE. Mean SCORAD reductions were 47% (95% confidence interval, CI = 38–55; algorithm) and 42% (95% CI = 29–54; individual). Clinical response was paralleled by improved quality of life in both groups. Physicians adhered to the algorithm option in 93% of their treatment decisions. Conclusion: Treatment following an evidence-based algorithm is an effective and applicable concept for the management of AE but does not show clear advantages compared to individualised treatment in a dermatological setting. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Background: Financial constraints challenge evidence of the effectiveness of dermatological inpatient management. Objective: To evaluate the effectiveness of hospitalization in atopic dermatitis and psoriasis regarding initial and sustained benefits. Methods: Prospective study on adults with psoriasis vulgaris (n = 22) and atopic dermatitis (n = 14). At admission, discharge, and 3 months after discharge, validated outcomes of objective and subjective disease severity were assessed by trained investigators. Results: Hospitalization resulted in substantial benefit in quality of life and clinical disease severity. Looking at mean scores, the observed benefit appeared stable until 3-month follow-up. The analysis of individual patient data revealed significant changes in disease severity between discharge and 3-month follow-up with some patients relapsing, others further improving. Reasons for hospitalization and treatment performed were not related to sustained benefit. Conclusions: In psoriasis vulgaris and atopic dermatitis, hospitalization effectively improved quality of life and clinical disease severity. Further research should focus on prognostic factors for sustained improvement. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Background: Pimecrolimus cream 1% is a non-steroid, selective inflammatory cytokine inhibitor indicated for atopic dermatitis (AD). Objective: To compare the safety and efficacy of pimecrolimus cream 1%-based treatment versus conventional therapy in adults with moderate AD. Methods: Patients were randomized to receive pimecrolimus cream 1% (n = 62) or vehicle (n = 68) at the first signs/symptoms of AD, for 24 weeks as required. A moderately potent topical corticosteroid (prednicarbate 0.25% cream) was allowed in both groups to treat flares. Results: Corticosteroids were required on fewer days in the pimecrolimus group, compared with the vehicle group (9.7 vs. 37.8%, p < 0.001). Furthermore, 59.7% of pimecrolimus-treated patients experienced no flares during the study period, compared with 22.1% of vehicle-treated patients (p < 0.001). Pimecrolimus cream 1% was well tolerated throughout the study. Conclusion: For adults with moderate AD, pimecrolimus cream 1% is well tolerated, reduces the incidence of flares, reduces/eliminates corticosteroid use, improves long-term disease control and enhances the patients’ quality of life. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Background: Pimecrolimus cream (Elidel®, SDZ ASM 981), a non-steroid inhibitor of inflammatory cytokines, is effective in the treatment of atopic dermatitis (AD). We assessed whether early treatment of AD signs/symptoms reduces the need for topical corticosteroids. Objective: To investigate the efficacy and safety of pimecrolimus cream 1% in the long-term management of adult AD. Methods: 192 adults with moderate to severe AD were randomised (1:1) for twice daily (b.i.d.) treatment of early signs or symptoms of AD with either pimecrolimus cream 1% or vehicle cream (control group) to prevent progression to flares. Treatment was given as needed for 24 weeks. In the event of flares, a moderately potent corticosteroid (prednicarbate 0.25% cream) was permitted as rescue medication in both groups. The percentage of days on which a topical corticosteroid was used to treat disease flares was the main outcome measure. Results: Corticosteroid medication was used on 14.2% (95% confidence interval, CI: 8.3–21.1) of the days of the 24-week treatment period in the pimecrolimus group and on 37.2% (95% CI: 30.4–44.0) of the days in the control group (p < 0.001). In total, 44.8% (43/96) of patients in the pimecrolimus group did not experience a flare compared with 18.8% (18/96) of patients in the control group. The median time to first flare was 144 days in the pimecrolimus group and 26 days in the control group (p < 0.001). Pimecrolimus treatment was also associated with improvement in signs and symptoms of AD, pruritus, patients’ self-assessment and quality of life. Conclusions: Pimecrolimus cream 1% b.i.d. is an effective, well-tolerated, long-term treatment for AD in adults, substantially reducing the number of flares compared to a conventional therapy and consequently reducing or eliminating the need for corticosteroid treatment. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Allergic manifestations are increasingly common in infants and children. Accumulating evidence suggests that the ‘epidemic’ increase of childhood allergy may be associated with environmental factors such as stress. Although the impact of stress on the manifestation and exacerbation of allergy has been demonstrated, the underlying mechanisms of stress-induced exacerbation are still obscure. A growing number of studies have suggested an altered hypothalamus-pituitary-adrenal (HPA) axis function to stress in allergic children. It is speculated that a dysfunctional HPA axis in response to stress may facilitate and/or consolidate immunological aberrations and thus, may increase the risk for allergic sensitization and exacerbation especially under stressful conditions. In the present review the potential impact of a hyporesponsive as well as a hyperresponsive HPA axis on the onset and chronification of childhood allergy is summarized. Moreover, potential factors that may contribute to the development of an aberrant HPA axis responsiveness in allergy are discussed. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Die Haut ist das größte Organ des Menschen und stellt die primäre Barriere gegen Umwelteinflüsse und Pathogene dar. Eine Dysbalance der Hautbarriere birgt die Gefahr einer nachfolgenden Entzündungsreaktion. Bleibt diese bestehen, können sich Hautkrankheiten wie zum Beispiel die atopische Dermatitis (AD) entwickeln. Verschiedene Zytokine wie Thymic Stromal Lymphopoietin (TSLP) werden bei entzündlichen Hauterkrankungen eine bedeutende Rolle zugeschrieben. Die Bedeutung von TSLP wurde zunächst anhand mehrerer Knockout-Mausstämme untersucht. Hier zeigte sich, dass TSLPR-KO und TNF-TSLPR-DKO Mäuse im Gegensatz zu TNF-KO Mäusen keine bzw. weniger Zeichen einer Entzündungsreaktion in der Haut entwickeln. Die Rolle äußerer Einflüsse auf die TSLP-Produktion wurde anhand eines Irritationsmodells ebenfalls in Mäusen untersucht. Dabei führte die Hautirritation, ausgelöst durch Abtragen der oberen Hautschichten mittels eines Tesa-Abriss, zu einem signifikanten Anstieg von TSLP in der Haut?. Mit Hilfe von Agonisten und Inhibitoren konnte gezeigt werden, dass dieser Irritations-vermittelte TSLP-Anstieg über Interleukin-1 (IL-1) und Protease Activated Receptor 2 (PAR-2) vermittelt wird. In diesem Zusammenhang wurde auch gezeigt, dass die Aktivierung von IL-1- sowie PAR-2-abhängigen Signalwegen zu einer gesteigerten Aktivität des TSLP-Promotors führte. Die Untersuchung der Wirkung verschiedener Mastzellmediatoren auf die TSLP-Expression ergab, dass Tryptase, über die Aktivierung von PAR-2, der wichtigste Mediator für den Anstieg von TSLP nach der Degranulation von Mastzellen ist. Dieses Ergebnis wurde mittels verschiedener in vitro, in vivo und ex vivo Experimentalansätze belegt. So konnte in einem c48/80-abhängigen Degranulationsmodell in Mäusen gezeigt werden, dss PAR-2- sowie Mastzell-KO Mäuse im Vergleich zu Wildtypen nach Injektion von c48/80 signifikant weniger TSLP exprimierten. / The skin is the first line of defense against environmental or microbial pathogens. A deviation of the skin barrier homeostasis by any kind of insult can result in an inflammatory response. The inflammatory response in turn can promote the development of an eczemaincluding atopic eczema. Thymic stromal lymphopoietin (TSLP) due to its pleiotropic nature play an important role in inflammatory disorders. The major aim of this thesis was to better understand the underlying mechanisms of TSLP production in the context of skin irritation and mast cell (MC) mediators and their contribution in the development of atopic dermatitis (AD). The role of TSLP was studied using TSLPR-/- mice. The data show that TSLPR-/- and TNF-/-/TSLPR-/- mice were protected from AD development, by contrast TNF-/- mice exhibited severe AD. The role of exogenous triggers was studied using tape stripping mediated skin irritation mouse models. Skin irritation resulted in significant enhanced TSLP production. TSLP induction was identified to depend on interleukin (IL)-1 and protease activated receptor (PAR)-2 pathways proven by using exogenous activators or inhibitors of these pathways. Moreover, PAR-2 and IL-1 concomitantly promoted NF-κB binding to the human TSLP promoter which in turn resulted in an increased TSLP promoter activity. Additionally, the role of mast cell mediators in the context of TSLP induction was investigated. Tryptase turned out to be the trigger responsible for the enhanced TSLP response by activating the PAR-2 pathway. This finding was proven by employing in vitro, ex vivo and in vivo approaches. In detail PAR-2-/- and MC-/- mice were used in a compound 48/80 (C48/80) dependent MCs degranulation model. PAR-2-/- and MC-/- mice produced significantly less TSLP in comparison to control mice.

The human skin is the largest and most complex body organ but accessible and attractive for biomarker sampling and transdermal drug delivery. The two procedures are significantly impacted by several biophysical properties of the skin, especially the pH and stratum corneum (SC)hydration. The varying levels of pH on the skin surface usually impact the permeability barrier function of the SC, contributing to the onset of dermatological disorders such as incontinence-associated dermatitis (IAD). Consequently, this scholarly work provides a comprehensive in vitro investigation of the effect of pH on the skin including the effect of artificial urine. The pig skin membranes were used to conduct electrical impedance spectroscopy (EIS)experiments using a four-electrode Franz cell set-up. Artificial urine and buffered solution with varying pH gradients were utilized to induce reversible changes in effective membrane capacitance (Ceff) and membrane resistance (Rmem). The in vitro investigation revealed that exposure to urine changed the electrical impedance properties of the skin. Specifically, we found that the application of artificial urine to the skin reduced skin resistance. At the same time, we also find systematic changes in skin capacitance. Skin capacitance increased with increased pH. Hence the two skin impedance parameters showed a clear effect of artificial urine on the skin. These changes, i.e., the decrease of Rmem and increase of Ceff of skin membranes when they are exposed to artificial urine, can be interpreted as skin barrier deterioration The information provided herein is relevant in describing the detrimental effect of urine on the skin, which probably makes skin barrier more permeable.

A dermatite atópica é uma doença de pele de caráter inflamatório crônico que normalmente precisa de tratamento com glicocorticóide tópico. O objetivo deste estudo foi avaliar o impacto da Dermatite atópica no consumo de nutrientes, no estado nutricional e no metabolismo ósseo de crianças com dermatite atópica moderada e grave comparadas à crianças saudáveis. Foram incluídas neste estudo 60 crianças de 4 a 12 anos com AD moderada/grave e 54 controles. O consumo alimentar foi avaliado por três recordatórios de 24 horas. O estado nutricional foi determinado pelo z-escore de altura para idade, peso por idade e do índice de massa corporal. Os marcadores ósseos séricos foram 25OH vitamina D, fosfatase alcalina óssea, cálcio sérico, fósforo, PTH, osteocalcina, CTX e cortisol. Os pacientes e familiares foram questionados quanto à fraturas, exposição solar e escore de atividade física. Por meio de densitometria dupla de Raio-X avaliou-se o conteúdo mineral ósseo (CMO), a densidade mineral óssea (DMO) e o z-score da coluna lombar, do fêmur total e do corpo inteiro. As crianças com dermatite atópica usavam glicocorticóide tópico em média por 3,9 ±1,81 anos. O tempo de exposição solar foi menor nas crianças com dermatite atópica. O consumo alimentar evidenciou um alto consumo de proteínas em ambos os grupos, e a ingestão de gordura foi mais baixo na crianças com DA. A média consumida de cálcio e vitamina D foi abaixo da recomendação nutricional em ambos os grupos. As crianças com DA apresentaram mais casos de rinite, asma e alergia alimentar do que o grupo controle. Segundo o zscore de altura para idade as crianças com DA foi significativamente mais baixas quando comparadas com o grupo controle. O CTX sérico foi menor no grupo DA. O CMO da coluna lombar foi mais baixo nas crianças com DA, e o CMO, a DMO e o z-score do fêmur total também foram significativamente menores no grupo DA do que no grupo controle. Neste grupo de crianças com DA, estudado o uso do glicocorticóide tópico pode ter diminuído a altura para idade, e a massa óssea. / Atopic dermatitis is an inflammatory allergic skin disease that often requires glicocorticosteroids therapy. The aim of this study was to determine the atopic dermatitis impact on food ingestion, nutritional status and bone mass in children with moderate to severe AD compared with a control group. Food ingestion was evaluated with 3 days 24-hour food recordathory. Nutritional status was determined with height to age z-score, weight for age z-score and BMI z-score. Bone markers measured in serum were 25OH vitamin D, bone phosphatase alkaline, CTX, serum calcium, phosphorus, osteocalcin, PTH and cortisol. Information on lifestyle parameters, bone fractures, sun exposure and physical activity were collected by use of a standardized questionnaire. Lumbar spine, total femur and whole body, bone mineral content (BMC), bone mineral density (BMD) and z-score was measured by dual-energy X-ray absorptiometry in 60 children (age 4-12years) with moderate to severe AD and 54 health controls, with the same age. In children, low BMD was defined as a Z-score less than -2. The AD children used topic glicocorticosteroids for a mean of 3,9 ±1,81 years. The sun exposure was lower in the AD group. Food ingestion showed high protein ingestion levels in both groups, and the fat consumption was lower in the AD children. The calcium and vitamin ingestion were bellow the recommendations in the two groups. Children with AD had more riniths, asthma and food allergy then control group. The CTX was lower in the AD group. The children with AD were significantly smaller according to the height for age zscore. There was significant smaller BMC on lumbar spine, and in the BMC, BMD and z-score in the total femur on the AD children. Low BMD occured more frequently in this population of children with moderate to severe AD compared with the control group. Use of topical glicocorticosteroids in the previous could be 5 years associated with the decrease in BMD.

A dermatite de contato alérgica decorre de uma reação imunológica, mediada por células T, contra um contactante em pessoas previamente sensibilizadas. O exame padrão ouro para o diagnóstico da DCA é o teste de contato (TC). Infelizmente, o TC demanda tempo, não é inócuo e tem algumas limitações. O teste de proliferação linfocitária (TPL) convencional, uma alternativa ao TC, apresenta baixa sensibilidade no diagnóstico de alergia ao cromo. A fim de aprimorar a sensibilidade o resultado do teste foi obtido pela detecção de citocinas no sobrenadante das culturas e não por timidina radiomarcada. Dezoito pacientes alérgicos ao cromo e 19 controles foram testados com o teste convencional e com as citocinas IFN-?, IL-2, IL-4, IL-5, IL-10, IL-12, IL-13, IL-17 e rantes. Houve correlação entre alergia ao cromo e detecção das citocinas IFN-gama, IL-2, IL-5, IL-12 e IL-13. Dessas, os melhores resultados foram encontrados com a IL-13. O TPL pode ser utilizado como exame adicional ou alternativo no diagnóstico da DCA pelo cromo / Allergic contact dermatitis (ACD) elapses from an specific T cell immunologic reaction against an allergen in a sensitized individual. The gold standard exam to confirm ACD is the patch test (PT). However, PT demands time, has potential side efects and some limitations. The standard lymphocyte proliferation assay (LPA) has sensitivity in the diagnosis of chromium allergy. To optimize this test the results were obtained by detection of cytokines instead radiolabeled thymidine. Eighteen patients allergic to chromium and 19 controls were tested with the conventional LPA and for the following cytokines: IFN-?, IL-2, IL-4, IL-5, IL-10, IL-12, IL-13, IL-17 and rantes. Correlation between allergy to chromium and detection of IFN-gama, IL-2, IL-5, IL-12 e IL-13 was found. The best results were found with IL-13. LPA can be used as an alternative or additional test in the diagnosis of ACD by chromium.

O progresso tecnológico na área da saúde permitiu desenvolver recursos materias como a fralda descartável com a finalidade de facilitar e melhorar as condições de trabalho dos profissionais de enfermagem bem como favorecer a qualidade da assistência e o conforto do paciente. Todavia, as evidências científicas do uso desse dispositivo não acompanharam a evolução tecnológica no mesmo ritmo o que pode ser observado pela ausência de estudos a respeito da assistência de enfermagem aos pacientes adultos hospitalizados que fazem uso de fralda descartável. O objetivo deste estudo foi analisar o impacto do uso de fraldas descartáveis no paciente adulto hospitalizado através do método de análise de sobrevivência. A amostra foi composta por 183 pacientes usuários de fralda descartável durante a hospitalização, internados através do serviço de urgência e emergência de um Hospital de Ensino referência para o atendimento de alta complexidade, na cidade de São Paulo, no período de março a maio de 2014. Os pacientes caracterizaram-se por serem do gênero masculino (62,3%), casados (30,1%), com idade média de 54,0 anos, provenientes da residência. Houve predomínio das afecções traumáticas, cardiovasculares e do aparelho digestivo. O tempo médio do uso de fralda descartável foi de 10,6 dias, sendo os trinta primeiros dias, período crítico para o desenvolvimento de infecção de trato urinário e lesões cutâneas relacionadas ao uso de fralda. Na amostra estudada as lesões cutâneas relacionadas ao uso de fralda tiveram incidência de 14,2% e as infecções do trato urinário tiveram incidência de 10,9%. A covariável gênero teve forte associação no desenvolvimento de infecção do trato urinário, com p< 0,5; as demais covariáveis para infecção do trato urinário, bem como o gênero e as covariáveis para as lesões cutâneas relacionadas ao uso de fralda foram descritas através de estatística descritiva por não apresentarem associação relevante. No Brasil, o presente trabalho destaca-se por ser pioneiro em caracterizar a população adulta usuária de fralda descartável, identificando aspectos relevantes ao cuidado de enfermagem necessários a uma assistência de qualidade, bem como pontuar o período crítico de prevenção para infecção de trato urinário e as lesões cutâneas relacionadas ao uso deste dispositivo, no qual devem ser concentradas as ações de vigilância / Technological progress in health has allowed to develop material resources such as the disposable diaper in order to facilitate and improve the working conditions of nursing professionals and also to support the quality of care and patient comfort. Nevertheless, the scientific evidences of the use of this device did not follow the technological developments in the same pace, which can be observed by the absence of studies on nursing care to adult hospitalized patients who use disposable diapers. The aim of this study was to analyze the impact of the usage of disposable diapers in the hospitalized adult patient by the method of survival analysis. The sample consisted of 183 patients, users of disposable diaper during hospitalization, admitted through the urgency and emergency services of a Teaching Hospital, reference in services of high-complexity care in the city of Sao Paulo, in the period from March to May, 2014. The patients were characterized by being male (62.3%), married (30.1%), with mean age of 54.0 years, and outpatients. There was a predominance on traumatic, cardiovascular and digestive tract conditions. The average time of disposable diaper usage was 10.6 days, the first thirty days being critical to the development of urinary tract infections and skin disorders related to the period of the diaper usage. In the studied sample, there was a 14.2% incidence of skin lesions related to diaper usage, and a 10.9% incidence of urinary tract infections. The covariate gender was strongly associated in the development of urinary tract infection, with p< 0.5; the other covariates for urinary tract infection, as well as gender and covariates for the skin lesions related to diaper usage were described using descriptive statistics since they did not present relevant association. In Brazil, this research stands out as being pioneer in characterizing adult disposable diaper user population, identifying relevant aspects to nursing care required for a quality service, and also pointing the critical period for the prevention of urinary tract infection and skin lesions related to the use of this device, to which surveillance actions should be concentrated