Case scenario 3 an adult with severe atopic eczema Questions
What is the role of systemic immunosuppressive therapy Immunosuppressive therapy is generally of proven benefit in the short- and intermediate-term (few months) management of atopic dermatitis. Immunomodulatory therapy (platelet activating factor, immunoglobulins, levamisole, etc.), however, is rarely used. We found immunomodulatory therapy to be poorly reported. We decided that the use of less concrete therapies such as anthelmintics and injections of antibodies antigen complexes should not be...
References
Precancerous dermatoses a study of two cases of chronic atypical epithelial proliferation. J Cutan Dis 1912 30 241-55. 2. Lee M, Wick M. Bowen's disease. Cancer J Clin 1990 40 237-42. 3. Frost C, Green A. Epidemiology of solar keratoses. Br J Dermatol 1994 131 455-64. 4. Vitasa B, Taylor H, Strickland P et al. Association of non-melanoma skin cancer and actinic keratosis with cumulative solar ultraviolet exposure in Maryland watermen. Cancer 1990 65 2811-17. 5. Schwartz R. The actinic...
ABV or BV chemotherapy versus liposomal anthracyclines
Three large randomised controlled trials have compared liposomal anthracyclines (either doxorubicin or daunorubicin) with standard ABV or BV combination chemotherapy. We found one randomised study comparing liposomal daunorubicin (DaunoXome) with ABV and two randomised trials comparing liposomal doxorubicin with standard combination chemotherapy (either ABV or BV).60-62 All three trials assessed response using modified ACTG response criteria and graded toxicity according to standard criteria....
Effectiveness Azathioprine
No systematic review and no RCTs inform us about the use of azathioprine. Its use is confined to certain specialists and, anecdotally, it appears to have limited efficacy. An ongoing RCT has been identified on the Cochrane Skin Group's ongoing clinical trials register (see http www.nottingham.ac.uk muzd) which is due to report in late 2002. Systemic prednisolone is commonly used in short bursts (a few weeks) for severe atopic eczema. The systematic review concluded that the potency of this...
Efficacy
Only four RCTs have been published in full in three papers at the time of this summary (two trials in adults, n 34 and n 260, and two trials in children combined into one, n 403).6-8 It is likely that there are many more unpublished and ongoing studies. In the first study, 34 patients with moderate atopic eczema were randomised within a right-left body comparison study.6 Topical 1 pimecrolimus (syn. with ascomycin) was applied twice daily (n 16) or once daily (n 18) and compared with the...
Photodynamic therapy PDT Efficacy
Four RCTs31-34 of different types of PDT reported varying success. Cure rates ranged from 8 (of patients) to 73 (of warts). One trial31 in 52 adults and children using a left-right design (randomising active and placebo treatments to warts on the left and right side of the body) showed resolution of warts in 40 of participants. In all those that responded to treatment, the warts on the placebo-treated side also resolved. In another trial in 40 adults,32 aminolaevulenic acid (ALA) PDT achieved a...
Methods of search
Systematic reviews and RCTs were identified using a search strategy published elsewhere.7 This was updated to September 2001 with a Medline and Embase search using the same strategy and supplemented by a search of the Cochrane Central Register of Controlled Trials (September 2001). The inclusion criterion for study selection was the mycological confirmation of the presence of fungi in the trial populations. The search found two systematic reviews, one of topical treatments for skin infections7...
Antihistamines firstgeneration H1 antagonists and H2 antagonists
Four studies compared the use of H1 and H2 antagonists or a combination. None of these studies had a placebo arm. Two studies compared diphenhydramine with an H2 antagonist (famotidine or cimetidine). Moscati et al. investigated the efficacy of a single-dose intramuscular cimetidine 300 mg with Summary of data from randomised controlled trials of the treatment of acute urticaria Itching, wheal intensity, sedation, wheal extent, overall Improvement on a 3-A point Diphenhydramine significantly...
Intralesional corticosteroids Benefits
One randomised controlled trial (RCT) and one observational comparison study confirm that intradermal injections of triamcinolone acetonide, 5 mg ml by a needle-less injector, produced rapid regrowth of hair in a high proportion of subjects with limited disease, within 4-6 weeks. What are the effects of treatment for patchy alopecia areata In a report of 84 patients using normalsaline controls, 86 of patients treated with triamcinolone responded, compared with...
Emollients and occlusive dressings
Psoriatic plaques are dry, scaly and frequently itchy. Emollients may help to soften psoriatic scale by increasing its water content, either by forming an occlusive layer on the skin surface (for example white soft paraffin) or by an osmotic effect (for example urea containing creams). Most topically applied therapies for psoriasis are formulated in emollient bases but emollients on their own are frequently advocated for psoriasis. They are claimed to reduce dryness, scaling and itch. There is...
Oral treatment
An early RCT compared oral itraconazole, 200 mg day, with topical clotrimazole, 200 mg day for 6 days, and with placebo in 95 patients. One week after the end of treatment 96 , 100 and 77 of the women, respectively, were clinically cured. Mycological cultures were negative in 73 , 95 and 32 . At 4 weeks no differences were found between itraconazole and clotrimazole. Side-effects were moderate and manageable but, as expected, were more frequent with itraconazole (nausea, headache) than with the...
Azole drugs
A number of RCTs have investigated the effect of newer azolic drugs in different cutaneous candidiasis variants. One RCT compared sertaconazole 1 and 2 cream in 10 patients, who used each for 28 days. Clinical, microscopic and microbiological parameters were evaluated. The cure was total for 19 out of the 20 patients, demonstrating high efficacy. There were no relapses of infection in any of the cured patients. No local or general effects were recorded during this trial.17 Another RCT enrolled...
Background Definition
Acne vulgaris is a pervasive disease of the pilosebaceous follicles of the skin, which are located on the face, back and chest. The disease has a range of clinical expression and can be classified according to the predominant lesion type. Non-inflammatory or comedonal acne is primarily composed of open comedones (blackheads) and closed comedones (whiteheads) with little or no inflammatory involvement. Inflammatory acne is characterised by inflamed lesions (pustules, papules and nodules) and can...
Systemic antifungal therapy for tinea capitis in children
Griseofulvin has been the most widely used and the most prescribed treatment for tinea capitis and has served as a standard for the evaluation of any newer agent to be considered for this infection. New drugs being used against other fungal infections in adults, such as ketoconazole, itraconazole, terbinafine and fluconazole, are being considered more frequently for the treatment of tinea capitis. Sufficient pharmacological and pharmaceutical data exist on these five antifungal drugs to make...
Case scenario 1 A child with atopic eczema of moderate severity
Figure 17.1 A child with flexural atopic eczema Figure 17.1 A child with flexural atopic eczema What is the role of emollients Efficacy We found no systematic review for emollients in atopic eczema. Five randomised controlled trials (RCTs) are reported here.1-5 Other studies were excluded because we could not ascertain if they were properly randomised they included conditions other than atopic eczema (for example Newbold6) or they presented only biometric data, the clinical relevance of which...
Singleagent chemotherapy Bleomycin
We found three small uncontrolled phase II trials of bleomycin as single-agent therapy in the treatment of AIDS-related KS and one small non-randomised study comparing singleagent bleomycin with combination ABV chemotherapy.42-45 In one non-randomised phase 11 study of single-agent bleomycin, 30 patients received intramuscular bleomycin, 5 mg day for 3 days every 14-21 days, and another 30 patients received bleomycin by infusion, 6 mg m2 day for 4 days every 28 days.42 The overall partial...
Intralesional chemotherapy
Two uncontrolled phase II studies have examined the effect of treating intraoral, oropharyngeal and laryngeal AIDS-related KS by intralesional injection of vinblastine.16,17 One obtained a 62 complete response rate (16 26 lesions) in 24 patients with AIDS-associated oropharyngeal or laryngeal KS.16 Lesions were injected with vinblastine, 0-1-0-2 mg ml repeated every 4 to 5 weeks until complete response or stable disease. Side-effects included self-limiting pain, and ulceration. In 11 of 24...
References for metastatic malignant melanoma
Balch CM, Reintgen DS, Kirkwood JM et al. Cutaneous melanoma. In DeVita VT Jr, Hellman S, Rosenberg SA, eds. Cancer Principles and Practice of Oncology, 5th ed. Philadelphia Lippincot-Raven 1997 1947-94. 2. Unger JM, Flaherty LE, Liu PY et al. Gender and other survival predictors in patients with metastatic melanoma on Southwest Oncology Group Trials. Cancer 2001 91 1148-55. 3. Crosby T, Fish R, Coles B, Mason MD. Systemic treatments for metastatic cutaneous melanoma. In Cochrane...
References Granlund H. Erkko
Veien NK, Larsen P0, Thestrup-Pedersen K, Schou G. Long-term, intermittent treatment of chronic hand eczema with mometasone furoate. Br J Dermatol 1999 140 882-6. In adults with chronic clinically active hand eczema, do protective or occlusive gloves, barrier-creams, avoidance of allergens and irrititants, and other non-pharmacological interventions lead to better patient- and doctor-rated sign scores than topical steroids 2. English JSC, Bunker CB, Ruthven K, Dowd PM, Greaves MW. A...
Prognosis
The majority of children with atopic eczema appear to grow out of their disease, at least to the point where the condition becomes a problem no longer in need of medical care. A detailed review of prognostic studies reported elsewhere2 concluded that most large studies of well-defined and representative cases suggest that about 60 of childhood cases are clear or free of disease symptoms in early adolescence. However, many such apparently clear cases are likely to recur in adulthood, often as...
Case scenario 2 How should infected atopic eczema be treated
The relationship between Staphylococcus aureus and atopic eczema disease activity has been debated for many years. Most physicians recognise clinically infected eczema as recent onset of weeping, oozing and serous crusting or overt pus overlying the eczematous lesions. In this situation S. aureus is isolated in 90-100 of cases, usually in high numbers.1,2 In around 30 of cases, beta haemolytic streptococci are also isolated.1 Clinical infection is undoubtedly a major problem for some atopic...
Number needed to treat
Because many interventions in medicine are of only modest effect, their apparent benefit may not be that noticeable after one has tried the intervention on a few patients. One way to understand the magnitude of benefit in relation to baseline risk is to use the concept of number needed to treat NNT .17 This refers to the number of patients that on average you would need to treat in order to see one additional success in the new treatment when compared with standard treatment. NNT is calculated...
