Alternative Remedies for Eczema

Eczema Free Forever by Rachel Anderson

Rachel Anderson, the author of this ebook claims that Eczema Free Forever is a unique treatment for eczema solution that covers proven methods, guides, and step-by-step techniques on how to treat eczema naturally, and fast. The Eczema Free Forever Now is a downloadable program which comes with comprehensive Guide Book, and a number of complementary bonuses. These include recipes for healthy natural fruit juices, all natural shampoo, lotion and facial scrubs, a helpful supplement guide and a list of 46 healing foods with great health benefits. The effectiveness of the methods offered in Anderson's book can depend on the determination of the individual. If a choice is made to create a overall healthy lifestyle those readers would have a far greater likelihood of experiencing the sought after results. Read more...

Eczema Free Forever Overview

Rating:

4.8 stars out of 41 votes

Contents: 80-page EBook
Author: Rachel Anderson
Official Website: www.eczemafreeyou.com
Price: $29.97

Access Now

My Eczema Free Forever Review

Highly Recommended

I've really worked on the chapters in this book and can only say that if you put in the time you will never revert back to your old methods.

In addition to being effective and its great ease of use, this eBook makes worth every penny of its price.

Case scenario 3 an adult with severe atopic eczema Questions

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 considered here. Instead, we have concentrated on commonly used systemic immunosuppressive agents such as photochemotherapy, ciclosporin, azathioprine and systemic steroids. We examined global indices of well-being and also disease-specific indices such as patient-assessed itch. The long-term morbidity associated with such potentially highly toxic treatments is unclear. Here we concentrate on short-term treatments of the crisis-intervention type, this being the most common use of immunosuppressive treatments in dermatology. Much of the information...

Allergic contact dermatitis

Allergic contact dermatitis is one of the best studied forms of delayed-type hypersensitivity and it is the result of sensitization to these small molecular compounds, also described as haptens. Molecules with a molecular weight under 500 Da are assumed to be bound by intraepidermal Langerhans cells, the major cutaneous representative of the family of dendritic antigen-presenting cells (APCs). These haptens are transported by Langerhans cells to the skin draining lymph nodes, where, in the paracortical T cell areas, induction of immunity to a given hapten may occur. It is thought that expansion of hapten-specific T cells in the lymph nodes is followed by dissemination of these T cells in peripheral blood and subsequently, perhaps through skin-specific homing, into the skin. Rechallenge of the skin then leads to elicitation of an eczema-type response, with presentation of haptens to specific T cells in the skin compartment. Well-known examples of contact allergens

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 Figure 17.2 Infected atopic eczema major problem for some atopic eczema sufferers.3 S. aureus is also isolated from the lesions of atopic eczema in 50-90 of patients without overt signs of infection.4,5 Here, the role that S. aureus plays is much less clear. The idea that it may contribute to disease activity has led to the development of many antimicrobial compounds and their widespread use in the management of clincally non-infected atopic eczema. This section evaluates the possible benefit of these agents, primarily for...

Contact Dermatitis Of The Face

Clinically, allergic contact dermatitis resulting from an aerosolized allergen presents as erythema or scale with or without vesiculation. The involvement is diffuse with upper and lower eyelids affected. This distribution is in contrast with photosensitive eruptions in which nonsun-exposed areas, such as the upper eyelids and the upper lip, are spared. Direct allergic contact dermatitis tends to be most prominent on the most sensitive skin, such as the eyelids. Examples of aerosolized contactants include rhus (poison ivy, oak) when the plant has been burned. Examples of common contactants affecting the face include nickel, nail polishes, toothpaste, preservatives in make-up, contact lens solutions, eyeglasses, and hair care products. Chemical-splash injuries are a common cause of facial-irritant contact dermatitis. A thorough history is necessary to uncover the offending agent. Referral to a dermatologist or allergist may be necessary if the history is unrevealing.

Herpes Simplex and Eczema Herpeticum

The vast majority of HSV type 1 or type 2 infections involve only localized areas of skin or mucous membranes. In neonates, and adults with atopic dermatitis, malignancy, immunosuppression, and the acquired immunodeficiency syndrome (AIDS), the HSV infection may disseminate, resulting in widespread vesicles, pustules, and ulcerations, and causing multisystem involvement. The neonate may acquire the infection either in utero due to maternal infection during pregnancy or during delivery. Adults undergoing chemotherapy or transplant recipients who are HSV seropositive may reactivate HSV and develop disseminated disease. Patients with atopic dermatitis are also at risk of disseminated disease, which is called eczema herpeticum.17 Eczema herpeticum is an association of two common conditions atopic dermatitis and HSV infection. The most severe forms of eczema herpeticum tend to occur in the young infant and the adult immunocompromised patient. Lesions appear initially in the area of the...

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 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 was difficult to ascertain (for example Pigatto et a .7, Hagstromer et al8). Kantor et al1 compared the use of an oil-in-water emollient (Moisturel) versus a water-in-oil emollient (Eucerin) using a left-right comparison design in 50 patients with symmetrical atopic eczema treated for 3 weeks. Test limbs affected by atopic eczema were treated once daily with the emollients and once daily with 2-5 hydrocortisone cream. Global severity showed a statistically significant reduction with both emollients compared with baseline. The 1998...

Atopic dermatitis

Atopic eczema, also known as atopic dermatitis, is a very common entity. One out of every 20 children will have an episode of atopic dermatitis during one or more periods of their lives. The disease is part of a syndrome known as atopy. It is genetically determined but the precise gene(s) responsible have not yet been identified. Other diseases that form part of atopy are extrinsic allergic asthma, rhinitis allergica, conjunctivitis allergica and certain forms of allergic food reactions. Individual patients may have any combination of these clinical entities. In many cases, atopic dermatitis takes a chronic form, with extremely itchy eczema lesions preferentially localized in the face, the neck, elbow folds and behind the knees. Stress may exacerbate the dermatitis, as may external irritants. The complicated and multifactorial etiopatho-genesis of atopic dermatitis has resulted in different models, including entirely psychosomatic and biochemical frameworks. The dermatological entity...

Eczema

Eczema can be part of a late phase IgE-mediated reaction or a delayed immune reaction to allergen, not mediated by IgE. Eczema is a common feature in people who do not have positive skin prick tests or IgE tests to the allergen. It is therefore only on the basis of a clinical improvement on exclusion of the food and relapse on reintroduction that the diagnosis can be made. Usually the only clinically useful test is an exclusion diet. Patch testing is being investigated as a diagnostic tool for food allergy, particularly in children.32

Atopic eczema

A proportion of young children with atopic eczema show an improvement when selected foods are excluded from their diet.16 Common foods implicated in the causation of eczema are egg and milk, and in some cases wheat and peanut. A detailed history and skin prick tests or RAST are sometimes helpful in identifying the food, but a negative test does not exclude the possibility of benefit from a food exclusion diet. If the child is sensitised to one or more foods on skin test or RAST, a trial diet excluding these foods should be prescribed for 4-6 weeks. If the child is not sensitised to foods, a trial of cow's milk and egg may be of value in children with extensive eczema. Eczema is a chronic disease and improvement with exclusion diet may not occur immediately. An open challenge should always be undertaken if an improvement has been observed to confirm the causative relationship. Doubleblind challenge may not always be feasible in clinical practice. Once the food(s) are identified, a...

Eczema Herpeticum

In individuals with cutaneous diseases, most commonly atopic dermatitis, HSV or VZV can infect the dermatitic skin. This disorder is referred to as eczema herpeticum or Kaposi's varicelliform eruption. Initially, the infection may be mistaken as an exacerbation or impetiginization of the dermatitis. Pustules or confluent areas of pus develop. Constitutional symptoms and adenopathy are usually present. Dissemination of the virus is possible mortality reports in this disorder are as high as 10 percent. Furthermore, scarring may be extensive if the viral infection is not treated early and aggressively.

Working things out on the basis of mechanism and logic

Some designer drugs such as topical tazarotene were promoted on the basis of their molecular mechanisms of action and may have appeared attractive at launch, but have been less exciting when tested in practice.5 It might also be argued that the frequent narration of the superantigen story as a mechanism for antistaphylococcal treatments for atopic eczema is a smoke screen that obscures the real lack or uncertainty of evidence of clear benefit for such agents.5

Step 1 Asking an answerable structured question

Developing a structured question that can be answered requires practice. An example of a useless question would be, Are diets any good in eczema . A better question, generated from a real clinical encounter, would be, In children with established moderate-to-severe atopic dermatitis, how effective is a dairy-free diet compared with standard treatment in inducing and maintaining a remission . Such a question includes four key elements Unless one uses such a structure, it would be easy to waste time discussing and searching for data on the role of diets in preventing atopic disease, the effects of dietary supplements such as fish oil, studies that evaluate only short-term clinical signs, and those that deal with a rag bag of different types of eczema in adults and children. Rzany discusses further examples of framing answerable questions in more detail in Chapter 5.

Step 3 Sifting information for relevance and quality

The usefulness of an article is a product of its clinical relevance times its validity divided by its accessibility.23 Information sources need to be near the clinical area if they are to be used for patients. Getting distracted by irrelevant but interesting citations is also a real hazard when reading search results. Two filters need to be applied if one is to keep practising EBD the first is to discard irrelevant information and the second is to spend more time looking at a few high-quality papers. Here it is timely to mention the concept of hierarchy of evidence,24 which is discussed in more detail in Chapter 7. This means that if two RCTs deal with the question of interest (for example dietary exclusion in childhood atopic dermatitis), or better still, a systematic

The visible nature of skin disease

Dermatology differs notably from other branches of medicine in the way it shades off into borderlands of cosmetics and cosmetic surgery, and in the often blurred boundaries between treatment, prevention and aggravation of skin problems. Even something as innocuous as washing can be a form of prevention (for example washing a chemical off one's hand), treatment (for example ridding the skin of an accumulation of excess scale) or aggravation (causing irritant contact dermatitis through frequent hand-washing with soap). The dual function of the skin as both a large and important organ and a superficial covering of the body that is important in social display can lead to trivialisation. Some skin conditions, like acne and vitiligo, are often considered purely cosmetic problems, particularly by some general practitioners.

Consumers and research

On calcinosis - a big problem for many people with the disease. This is not a particularly attractive topic and can be difficult to tackle. After several months waiting for a worthwhile proposal, a project was started in 2002. The association is also keen to fund a project to investigate the causes of childhood scleroderma. It is also worth noting that the UK National Eczema Society supported and funded the double-blind controlled study conducted at Liverpool University of the effect of housedust mites in adults and children with eczema.7 Other organisations, such as the National Eczema Association for Science and Education based in the USA, have set up and supported international research meetings. PSGs can play an important role in educating patients about ways in which they can become involved in clinical research. The National Eczema Society recognised this and encouraged its members and other dermatology patient groups to volunteer to join the Cochrane Skin Group (see Chapter 4)...

Asking an answerable question By

Again, although it might seem that only the dermatologist can appraise the validity of the data by checking for things such as adequacy of concealment of the randomisation schedule, and issues of blinding and intention-to-treat analysis, such an assessment is of little value if the dermatologist examines reported outcomes in a trial that means little to the patient. Consumers are ideally placed to help inform dermatologists about which aspect of the disease is important to them. For example, in patients with atopic eczema, is it short-term control of itching, duration or frequency of remissions, healing painful cracks in the fingers, coping skills, or ability to take part in sport and social activities

The role of consumers

Consumer involvement has been a strong feature of the CSG from the very beginning. This is because skin disease greatly affects the quality of life of the individual and because much of the trial work in skin disease has been dominated by answering questions that are important to the pharmaceutical industry. Consumers help us to redress that imbalance. At present (Autumn 2002) the skin group has 55 groups working on topics, both common and rare, such as acne, alopecia, bullous pemphigoid, eczema, excessive sweating, psoriasis, skin cancer and vitiligo. About 30 active consumers are involved at many levels. Initially they were recruited mainly through the National Eczema Society and the Vitiligo Society, but since we decided to always include a relevant consumer in the peer-review process, more consumers have become involved in this way. Increasingly consumers also take part in writing the review two of the reviews in preparation have a consumer as lead author.

Additional empirical criteria Disease definition

Therefore, as someone with an interest in atopic eczema, I would not trust a study that claimed a beneficial effect for a new treatment if the study included both children and adults with diverse eczematous dermatoses,14 as people with such conditions might respond differently.15 Similarly, the definitions of disease used may be an important quality criterion. For example, if I were reading the report of an RCT of an intervention for bullous pemphigoid, I would want to know that the diagnosis in study participants was confirmed by immunofluorescence in order to distinguish it from other bullous disorders of diverse aetiologies and with differing treatment responsiveness.

Groups are different from individuals

Even if the person in front of you is a German woman with acute atopic eczema, the results of the trial may not translate to real clinical benefit to her for several reasons. First, because the treatment effects reported in clinical trials, whether this is a mean change in severity score or proportion of people cleared, refers to groups of people. In a group of patients with a summary treatment effect such as a mean change in SCORAD (SCORing Atopic Dermatitis) of 5 points, there will be some individuals with score changes of 10 or 15 points, some with changes of 3 or 4, some with no change, and possibly some whose disease worsened. For example, closer inspection of the trial data on sildenafil (Viagra) for the treatment of erectile dysfunction7 suggested that some men had all the fun It follows that the patient sitting in front of you might benefit a lot or very little from the proposed treatment, and one has little way of knowing, apart from trying the treatment and seeing what...

Too many scales and too many shortterm studies

Given the profusion of scales used in dermatology (there are at least 13 named and at least 30 unnamed scales in atopic eczema alone15), it is quite easy to introduce bias by choosing a scale which contains features that will enhance your product when compared with competing products. Introduction of a new scale is another potential source of bias since they can increase the likelihood of showing a treatment benefit.16 Lack of suitable long-term outcomes is another problem frequently encountered in dermatology clinical trials. For example, atopic eczema is a long-term condition for most sufferers, yet of the 272 RCTs conducted to date, most have been less than 6 weeks' duration.12 Other factors such

Rare but serious sideeffects

Treatment benefits in clinical trials. Details of reasons for withdrawals are frequently missing altogether in trial reports, and failure to perform an intention-to-treat analysis may compound this because dropouts may be related to lack of efficacy or to adverse events which are not obviously related to the trial medication.19 Rare side-effects are unlikely to show up in small clinical trials and often emerge as subsequent case reports or during post-marketing surveillance. Simply stating that no serious liver problems occurred in 100 patients taking traditional Chinese herbs for atopic eczema is still compatible with an upper 95 confidence limit of 3 if a larger population were tested.20

What are the patients values Values and belief models

Sometimes, patients prefer to use something that they perceive to be more natural, for example evening primrose oil rather than synthetic topical corticosteroids for atopic eczema. Sometimes patients prefer to forgo pharmacological treatment and instead undertake various measures to manipulate their environment. Others just prefer to take a few pills and forget about it. Some like creams, others like ointments. Some people do not wish to be involved in lengthy discussions of treatment options if indeed they believe that their doctor is the best person to help them choose a treatment option. For example, a person with a basal cell carcinoma may be happy to be recommended surgical excision rather than debate the 10 or so treatment options available to treat such lesions.

Background Definition

The term hand eczema implies an inflammation of the skin (dermatitis) that is confined to the hands. Clinically, the condition is characterised by signs of redness, vesicles (tiny blisters), papules, scaling, cracks and hyperkeratosis (callous-like thickening), all of which may be present at different points in time. Itch, sometimes severe, is a common feature. Microscopically, the disease is characterised by spongiosis with varying degrees of acanthosis, and a superficial perivascular infiltrate of lymphocytes and histiocytes.

Incidenceprevalence

Hand eczema is considered a common condition, with a point prevalence of 1-5 among adults in the general population, and a 1-year prevalence of up to 10 , depending on whether the disease definition includes, more pronounced or mild cases. The prevalence may be higher in some countries. Recently, a decreased prevalence was stipulated, attributed to decreased occupational exposure to irritants. Hand eczema is twice as common in women than in men, with the highest prevalence in young women. Reasons for this sex difference are unknown, although greater exposure of women to wet work is probably contributory. Reliable data on incidence are scarce, and are mainly confined to estimates in particular occupational groups. Estimates vary from 0-5 per 1000 in the general population to 7 per 1000 per year in high-risk occupations such as bakers and hairdressers.

Implications for clinical practice

The choice for an optimal topical steroid treatment schedule cannot be derived from the current literature on hand eczema trials. Evidence from studies on other eczematous diseases may have to be considered. In adults with chronic hand eczema, are oral immunosuppressive agents (ciclosporin, methotrexate, mycophenolate mofetil) better in maintaining a long-term (more than 6 months) reduction of patient- and doctor-rated scores than topical corticosteroids

Hywel Williams Kim Thomas Dominic Smethurst Jane Ravenscroft and Carolyn Charman

Since at least 47 groups of interventions have been tried in atopic eczema, coverage of all therapy-related issues for atopic dermatitis is not possible, even in a chapter of this size. Instead, we have opted to introduce the evidence base for treating atopic eczema by means of three common clinical scenarios 1. a child with moderately severe atopic eczema 2. a person with clinically infected atopic eczema 3. an adult with severe atopic eczema. Much of the background work and methodology within the sections has been based (with updates) on the results of the UK National Health Service (NHS) systematic review of atopic eczema treatments which was published at the end of 2000. For a more comprehensive and detailed assessment of important areas, such as disease prevention, not covered in this chapter, readers are recommended to read the relevant sections of this report which is available free in the public domain (http www.ncchta.org). Subsequent editions of this book and the book...

Definition and diagnostic criteria

Atopic eczema is a chronic inflammatory skin condition characterised by an itchy red rash that favours the skin creases such as the folds of the elbows, behind the knees and around the neck. The morphology of the eczema lesions themselves varies in appearance from vesicles to gross lichenification on a background of poorly demarcated redness. Other features such as crusting, scaling, cracking and swelling of the skin can occur.1 Atopic eczema is associated with other atopic diseases such as hay fever and asthma. People with atopic eczema also have a tendency to dry skin, which makes them vulnerable to the drying effects of soaps. Atopic eczema typically starts in early life, with about 80 of cases starting before 5 years of age.2 Although the word atopic is used when describing atopic eczema, it should be noted that about 20 of people with otherwise typical atopic eczema are not atopic as defined by the presence of positive skin-prick test reactions to common environmental allergens...

Implications for practice

Although topical steroids have been used for the treatment of atopic eczema for over 40 years, surprisingly little work has been done to understand how best to use them for the long-term control of atopic eczema. Most RCTs have compared me-too products in studies lasting only a few weeks instead of addressing important questions such as optimum duration of application and whether one should use short bursts of potent steroids followed by milder preparations, or vice versa. The short-term studies have failed to evaluate speed of onset of one type of steroid when compared with another - an important consideration when trying to control the symptoms quickly in the child depicted in the case scenario. Despite widespread concern

Comment and clinical implications

Table 17.6 Randomised controlled trials that have evaluated treatments for clinically infected atopic eczema Table 17.6 Randomised controlled trials that have evaluated treatments for clinically infected atopic eczema eczema. Most had Infected eczema did not infection eczema atopic eczema atopic eczema poor 60 atopic dermatitis atopic eczema in Infected atopic eczema atopic eczema of eczema these atopic dermatitis eczema for eczema Table 17.7 Randomised controlled trials that have evaluated antiseptics for atopic eczema Table 17.7 Randomised controlled trials that have evaluated antiseptics for atopic eczema atopic eczema with atopic eczema atopic eczema aged similar eczema atopic eczema common practice to prescribe a short course of oral antibiotics in acute infected eczema. There is some evidence to support this, and no evidence of a detrimental effect. In contrast, there is no evidence to support the use of longer-term antibiotics in people with atopic eczema whose skin is...

Being explicit and systematic

Traditional expert reviews are fine for raising issues for discussion, but they are less suitable for summarising treatment efficacy. The unsystematic approach used in such traditional reviews often means that they are more prone to bias and hidden agendas.3 We have all done this in our traditional review articles in the past, and I admit having used the file drawer method to search for articles for my review of atopic eczema in 1995 (Figure 54.1).4

Influencing the agenda of future dermatology trials

It is quite clear from the systematic review of 300 or so RCTs in atopic eczema that most trials have reflected the agenda of the drug industry in order to license a particular me-too product, and that many questions that are important to clinicians and patients remain unanswered.10 Many of the outcome measures used in these trials are clinical scoring systems that may show up treatment effects, yet their clinical significance in practice is often obscure.

A threat of reductionism

Meta-analysis, which refers to the statistical pooling of results drawn from several studies, is prone to dangerous reductionism in terms of adding together studies that it does not make sense to combine.14,15 Thus, before contemplating playing with any statistics, it may seem sensible not to combine studies of childhood atopic dermatitis with those dealing exclusively with adult atopic dermatitis, as they may belong to a different disease group in terms of the aetiology of treatment responsiveness. It may also be sensible not to combine studies of atopic eczema that evaluate one sort of dietary exclusion with another. It may not make any sense to pool a clinically obscure outcome measure such as a doctor-assessed itch simply because it was the only outcome that was common to all trials.10 Meta-analyses are only as good as the data from the individual studies that make up such analyses, and great care needs to be taken to avoid adding together things that should not be combined,...

Effectiveness Azathioprine

Systemic prednisolone is commonly used in short bursts (a few weeks) for severe atopic eczema. The systematic review concluded that the potency of this approach beyond that of placebo was large (Table 17.8).2,4,10 There are no trials that properly evaluate the treatment according to Helsinki protocols (i.e. against another validated form of immunosupression such as ciclosporin). The trials also did not report long-term relapse rates or follow up disease severity. 4-0 mg ml Injection v atopic dermatitis 27 children with moderate-to-severe atopic eczema 20 children with severe atopic dermatitis Randomised controlled trials of phototherapy and photochemotherapy in atopic dermatitis atopic eczema and atopic eczema atopic eczema atopic dermatitis, atopic dermatitis, one CI, confidence Intervals NBUVB, narrow-band UVB MED, minimal erythema dose (I.e. minimal dose to produce redness) 8-MOP, 8-methoxypsoralen SCORAD, severity scoring of atopic dermatitis VAS, visual analogue scale

Further information

National Eczema Association for Science and Education 1220 SW Morrison, Suite 433, Portland, OR 97205, USA. Tel +503 228 4430 or +800 818 7546 fax +503 224 3363 website http www.eczema-assn.org National Eczema Society Hill House, Highgate Hill, London N19 5NA, UK. Tel +44 (0)20 7281 3553 fax +44 (0)20 7281 6395 website http www.eczema.org Address as National Eczema Society website http www.skincarecampaign.org

Aetiology

Contact irritants are the commonest external causes. Hand eczema caused by such irritants, or mild toxic agents, is called irritant contact dermatitis. Causal factors that are less common than irritants are contact allergens. Hand eczema caused by skin contact with allergens is called allergic contact dermatitis. Ingested allergens (for example nickel) may also provoke hand eczema. Water is a contact irritant and thereby an external causal or contributing factor. Being atopic (a tendency to develop asthma, hay fever or eczema) is the major predisposing factor responsible for hand eczema. There are several types of hand eczema of which the cause or predisposing factor is unknown. These (partly overlapping) types are not precisely defined and are commonly described as hyperkeratotic, tylotic, endogenous, dyshidrotic, pompholyx and nummular. In particular, dyshidrotic eczema is the subject of debate a hallmark is recurrent vesiculation, which may or may not...

Methods of search

Because of the tendency of hand eczema to develop a chronic or relapsing course, all questions below deal with chronic hand eczema. In the context of this chapter, chronicity can arbitrarily be defined as more than 6 months' duration. Because prescription topical corticosteroids are the most common treatment at present, they are the major comparator in the questions below. In adults with chronic hand eczema, do topical corticosteroids lead to better patient-and doctor-rated reduction in symptom scores than topical coal tar preparations In adults with chronic hand eczema, do short bursts of potent topical corticosteroids (class 3 or 4) lead to better patient- and doctor-rated scores than continuous mild (class 1 or 2) topical steroids

Morbidity and costs

Atopic eczema usually accounts for the worst disturbance in quality of life when compared with other dermatological diseases. Specific aspects of a child's life affected by atopic eczema are7 In financial terms, the cost of atopic eczema is potentially very large. One study of an entire community in Scotland in 1995 estimated that the annual personal costs to patients with atopic eczema was 297 million if extrapolated to the entire UK.13 The cost to the UK NHS was 125 million and the annual cost to society through lost working days was 43 million, making the total expenditure on atopic eczema 465 million per year. This figure is likely to be an underestimate since the prevalence of atopic eczema is lower in Scotland compared with the rest of the UK. Another study from Australia found that the annual personal financial cost of managing mild, moderate and severe eczema was Aus 330, Aus 818 and Aus 1255 respectively, which was greater than the costs associated with asthma in that study.14

Aims of treatment

Cure is an unrealistic option for the majority of sufferers, the causes of atopic eczema that are amenable to manipulation being poorly understood, and because the effect of conventional treatment on the long-term natural history of the disease is simply not known. Treatment is thus aimed at relieving troublesome symptoms such as itch and soreness and its associated sleep loss, in order to improve the person's quality of life. Improvement in skin appearance may also be important, as is self-esteem, social confidence and the ability to participate freely in recreational activities such as swimming.

Relevant outcomes

Outcome measures used in trials have been reviewed by Finlay.25 Most outcome measures have incorporated some measure of itch, as assessed by a doctor at periodic reviews or patient self-completed diaries. Other more sophisticated methods of objectively recording itch have been tried. Finlay drew attention to the profusion of composite scales used in evaluating atopic eczema outcomes. These usually incorporate measures of the extent of atopic eczema and several physical signs such as redness, scratch marks, thickening of the skin, scaling and dryness. Such signs are typically mixed with symptoms of sleep loss and itching, and variable weighting systems are used. It has been shown that measuring surface area involvement in atopic eczema is fraught with difficulty,26 which is not surprising considering that eczema is, by definition, poorly defined erythema. Charman et al. performed a systematic review of named outcome measure scales for atopic eczema and found that of the 13 named scales...

Comments

All studies were randomised but method and concealment of allocation were not described. All were described as double-blind, except Latchman et al.,29 where no blinding was mentioned. No ITT analysis was carried out. It is also questionable whether the placebo plants were truly inert. The study by Sheehan et al26 reported large effects in children, highlighting a promising treatment of atopic eczema. This has not been replicated in the other studies, although they are all quite similar. Clearly larger scale RCTs of longer duration are needed.

Effectiveness

Only two RCTs evaluating systemic antibiotics for clinically infected eczema were located.2,7 For non-infected eczema Two further important RCTs have compared systemic antibiotics with placebo in the treatment of non-clinically infected atopic eczema. In the first,8 oral flucloxacillin 250 mg four times daily for 4 weeks showed no benefit over placebo in terms of clinical efficacy, despite significantly reducing S. aureus counts. The second study9 showed a similar absence of benefit for 2 weeks oral cefuroxime. Rapid recolonisation occurred in both groups after cessation of treatment.

Prevention

The European multicentre study ETAC (Early Treatment of the Atopic Child) investigated the preventive effect of long-term (18 months) administration of cetirizine 0-25 mg kg twice daily in 1-2-year-old children with atopic eczema and positive family history of allergies.14 On addition to the primary endpoint (asthma), symptoms typical for acute urticaria were recorded in a diary during the intervention period

Pathophysiology

Of marrow-derived cells or allergenic over stimulation that causes secondary abnormalities. Some studies have suggested a defect in lipid composition and barrier function in people with atopic eczema - a defect which is thought to underlie the tendency to dry skin and possibly the enhanced penetration of environmental allergens and irritants, leading to chronic inflammation.

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 hand eczema. The most consistent factors that appear to predict persistent atopic eczema are early onset, severe widespread disease in infancy, concomitant asthma or hay fever, and a family history of atopic eczema.

Overreliance on RCTs

Whilst RCTs may be the most robust study design for minimising bias for conventional evaluation of the effectiveness of interventions for skin diseases, they have their limitations.18 In some circumstances, it may be impossible or unethical to perform an RCT. For example, it is unlikely that mothers will agree to be randomised to breastfeeding or bottle-feeding to see whether either prevents atopic eczema. Similarly, it would be impractical to randomise medical students to one form of education and others to another within the same class, because they would not be blinded to the interventions, and there may be considerable contamination of the intervention from one group as students talk together. Just because it is an RCT does not mean that it is a good RCT, and attention to quality is important here rather than just blindly following the concept of the hierarchy of evidence.12 Rare but serious events, which are extremely important when evaluating the pros and cons of a new...

Type I hypersensitivity

Factors determining IgE rather than IgG production are not fully understood however, the nature of the antigen-presenting cells may be relevant. In atopic eczema and allergic rhinitis Langerhans cells which are HLA-DR positive and bear high-affinity IgE receptors have been described. Class switching to IgE is promoted by cytokines IL-4 and IL-13 and is inhibited by interferon y. In atopics increased levels of Th2 type T cells producing IL-4 have been described, e.g. in vernal conjunctivitis.

Benefits of Breast Feeding

A large-scale study involving more than 17000 infants in which breast feeding promotion was randomized and morbidity results analyzed on an 'intention to treat' basis, with breast feeding promotion as the treatment, also provides evidence of causality. Infants born in hospitals and provided care in clinics randomized to breast feeding promotion were 40 less likely to have more than one case of gastrointestinal infection and 50 less likely to have atopic eczema than infants not randomized to this intervention (Figure 3). The intervention significantly increased the duration of exclusive breast feeding at 3 months from 6 to 43 and the duration of partial breast-feeding at lyear from 11 to 20 . Therefore, this study proved through a causal design that better breast feeding practices reduce risk of diarrhea and eczema, and that hospital and clinic-based interventions can result in large-scale shifts in behavior.

Epidemiology of Celiac Disease

The sister condition of celiac disease is dermatitis herpetiformis, which is the skin manifestation of gluten-sensitive enteropathy. It is an extremely itchy immunobullous disease that affects the extensor surfaces of elbows, knees, buttocks, the hairline, and the torso and is much less common than celiac disease. Probably the ratio between the two in geographic areas where both have been estimated is approximately 10 1. However, in countries where there has traditionally been less celiac disease awareness, such as North America, the ratio may be closer to 3 1.

Application to the diagnosis of food allergy

Foodstuffs are an uncommon cause of immunologically mediated contact dermatitis, although regular contact with vegetables and meat can certainly irritate intact or eczematous skin. Plant-derived saps such as from poison ivy and poison oak can cause a characteristic contact dermatitis. There exists cross-reactivity with these saps and mango skin and the oil from cashew nut shells. Some clinicians claim an exacerbation of eczema atopic dermatitis in patients who are patch test positive to nickel, cobalt and balsam of Peru, following oral ingestion of foods containing these substances. They similarly claim an improvement in these patients' conditions when they manipulate their diet to reduce the amount of these substances. There is some double-blind placebo-controlled evidence to support this, although there are some problems with the study design, in particular with the amount, source and form in which the salts are ingested. An exacerbation of eczema following oral ingestion of foods...

Foods commonly associated with allergy Table

Yunginger et al.3 and Sampson et al.4 showed the most common cause of severe food-related allergic reactions in adults and older children to be peanuts, crustaceans, shellfish, tree nuts and fish. In selected American children with atopic dermatitis (eczema), Burks et al.5 showed that skin prick testing with eight foods identified 99 of subjects who reacted to a food in DBPCFC, even if the food causing the reaction in the challenge had not been one of the foods used for skin testing. Or, put another way, subjects who reacted to an unusual food nearly always had a positive skin prick test (SPT) to one of the eight foods used for screening with or without associated symptoms on exposure to that food. Such studies need to be repeated in different populations of subjects. There are clearly geographical variations regarding these foods because the lists involved in reactions in Britain6 are like American lists but European studies give slightly different figures regarding allergic...

Disorders associated with food allergens

According to several clinical studies, the frequency of food-mediated asthma varies from 0.3 to 8.4 of asthma in patients aged under 15 years of age and is somewhat less frequent in adults. It is of interest to note that in studies where correct provocation tests have been undertaken, the percentage of true food-induced asthma is much lower than in those studies in which the diagnosis was made only by means of skin tests and or the determination of spe cific IgE. In some cases, the route of sensitization is clearly gastrointestinal (flour, egg, vegetables) in other cases, inhaled allergens are the triggering factors (smell of fish, metabisulfites, garlic, etc.). As mentioned above, food-induced asthma is in most cases only part of a more complex clinical picture. Eczema is a frequent event, particularly in infants however, urticaria and nasal problems, among other symptoms, constitute a multifocal hypersensitivity syndrome. The diagnosis is difficult because of the coexistence of true...

Diagnosis and mechanisms

An alternative approach is to introduce a 2-3 week - sometimes longer in eczema patients -oligoallergenic diet, which should include rarely-consumed food such as exotic fruit (no citrus fruit) or cooked vegetables when there is no pol-linosis present. 8. Delayed reactions, such as atopic eczema, respond to a provocation test with a delay of 8-24 h

Approach to food avoidance

Unconfirmed food intolerance (food known or suspected) If the food is known or suspected either from the history or from skin test or RAST, a trial exclusion diet is recommended. The period of exclusion depends, to some extent, on the type and frequency of reaction. If the subject is having frequent symptoms, for example urticarial episodes several times a week or diarrhoea, exclusion for a couple of weeks might be sufficient to gauge the response. For atopic eczema or chronic recurrent urticaria, a longer period, i.e. 2-3 months, may be required to assess improvement, allowing for spontaneous fluctuation in the disease severity. If significant improvement is observed on a trial exclusion diet, then open or DBPCFC should be performed.6 An open challenge or reintroduction of the food in the diet may be sufficient if an objective improvement has been observed, for example if the frequency and severity of urticaria or severity of eczema assessed objectively with a standardised score has...

Cutaneous Manifestations

Generalized cutaneous conditions, such as xerosis (dry skin), seborrheic eczema, and pruritus, are common and may be manifested prior to development of opportunistic infections. Treatment is with emollients and, if necessary, mild topical steroids. Pruritus may respond to oatmeal baths and antihistamines. Other infections, including S. aureus (manifested as bullous impetigo, ecthyma, or folliculitis), Pseudomonas aeruginosa (which may present with chronic ulcerations and macerations), and syphilis are frequently seen and should be treated with standard therapies. Several specific dermatologic conditions are discussed in more detail below. Intertriginous infections with either Candida or Trichophyton are often seen in patients with HIV and can be diagnosed by microscopic examination of potassium hydroxide preparations of lesion scrapings. Treatment includes topical imidazole creams, such as clotrimazole, miconazole, or ketoconazole. Scabies occurs in about 20 percent of HIV-infected...

Other symptomatic treatment

Ketotifen with antihistaminic and anti-inflammatory properties has been used in food allergic reactions such as urticaria and bronchospasm. It may be useful as an additional therapy in some patients. Beta-2 agonists such as salbutamol or terbutalin may be used when bronchospasm is a prominent feature in an allergic reaction. These drugs can be delivered by inhalation through a metered dose inhaler, in an aerosol form through a nebuliser, or by intravenous route. Food-related eczema and rhinitis should be treated along the standard line with topical steroids and antihistamine in addition to allergen avoidance.

Associated immunopathology

To produce a more severe clinical course. Dermatitis herpetiformis is a disease characterized by deposition of IgA at the dermal-epidermal junction. Here again, components of the alternative pathway of complement are deposited along with IgA. Dermatitis herpetiformis is often associated with elevated levels of gliadin-specific antibodies and the clinical course of some patients may be reduced by a gluten-free diet. A bullous disease of childhood has been described in which linear deposits of IgA are detected along the basement of affected subepidermal areas, suggestive of the deposition of specific anti-basement membrane IgA antibodies.

Possible Implications Of Observations In Rat In Human Behavior

Attention-deficit hyperactive disorder (ADHD) is known to be typical among atopic patients (Stevens, 1995, 1996). Atopic dermatitis is treated effectively with steroidal anti-inflammatory drugs and other antiallergic drugs that exert their effects mainly by inhibiting the cascade of LA ARA lipid mediators of allergic, inflammatory reactions receptors (LA cascade). Clinically, decreasing the intake of LA and increasing the intake of n-3 fatty acids that are competitive effectors of the LA cascade and partial agonists for the lipid mediator receptors were shown to be effective for the prevention of atopic dermatitis (Kato, 2000) and other allergic hyperreactivities (Ashida, 1997). In rodents suffering from n-3 fatty acid deficiency, the observed decrease in the feedback suppression of negative responses in the brightness-discrimination learning test (Fig. 3) and the increase in anxiety in the elevated plus-maze test (Nakashima, 1993) appear to have characteristics common to ADHD in...

Allergic skin diseases

These allergic diseases are usually assumed to be associated with a type I hypersensitivity reaction involving, in part, IgE, mast cells, Langerhans' cells and T-cells. While there is extensive knowledge of the role of these elements in human, and to some extent canine, atopic dermatitis, the allergic cat remains their poorly understood companion (see review by Roosje etal, 2002). In human atopic dermatitis Langerhans' cells can also bind IgE via the high-affinity FceRI receptor and then present antigens to T-cells in the dermis and local lymph nodes (Leung, 2000). Evidence for the role of T-cells in the dermis of cats with allergic dermatitis has been reported and Langerhans' cells have been shown to migrate to local lymph nodes (Roosje et al, 1997, 1998 Marchal et al, 1998). The T-cells were shown to be positive on double staining with anti-CD4 and interleukin-4 (IL-4) antibodies, in keeping with studies performed in human atopic dermatitis where IL-4 is an important component of...

Disorders Involving the Foreskin

Differential diagnostic considerations include penile infections (balanoposthitis), idiopathic penile edema (insect bites, contact dermatitis, etc.), and, more important, a circumferentially constricting foreign body (hair, clothing, rubber band, etc.). Among the most pressing duties of the examining physician is the identification and removal of any constricting foreign body. The profound edema of the glans penis and the foreskin may make this task exceedingly difficult. BALANOPOSTHITIS Balanitis is an inflammation of the glans penis. Balanoposthitis is an inflammatory process that also involves the foreskin. The cause of balanoposthitis in preadolescent boys is usually infection but may occasionally be trauma, including chronic friction, zipper injuries, and contact dermatitis, or a fixed drug eruption (tetracycline or clotrimazole). Even rarer are plasma-cell balanitis and balanitis xerotica obliterans. As many as 3 percent of boys experience balanoposthitis, the vast majority of...

Pagets disease of the nipple

Paget's disease of the nipple was first described over 200 years ago by Sir James Paget. Clinically, this is recognised by reddening, excoriation and or scaling of the skin of the nipple with or without a nipple discharge (Fig. 17.29). These appearances may resemble eczema or dermatitis but are unilateral. This is associated with an underlying intraduct carcinoma and up to one-half of the patients have a palpable lump. If there is a palpable lump present then up to 90 of this group of patients will have an invasive cancer present. In the absence of a palpable lump up to one-third of patients will have an invasive cancer.

TABLE 785 Pruritus

Dermatologic conditions contributing to this symptom complex include atopic dermatitis, lichen planus, psoriasis, and seborrheic dermatitis. Any of the anal margin neoplasms, particularly Bowen's disease and extramammary Paget's disease, may initially manifest itself as pruritus.

Skin Disorders Affecting The Nipple And Breast

Atopic dermatitis, which may affect one or both nipples, is manifested by areas of fissuring, weeping skin, or lichenification. This condition occurs in both pregnant and nonpregnant women, most commonly between the ages of 15 and 30. This dermatitis is more common in atopic individuals. Underlying causes of these skin changes include scabies, contact allergy, local medication reaction, and irritation secondary to friction. 5 Paget's disease is an uncommon neoplastic disorder that usually begins at the nipple and spreads outward, secondarily involving the areola. This is an important distinction, since benign skin conditions begin on the areola. The appearance ranges from that of an eczema-like erosion of the nipple to a red, raw surface, with a copious, clear discharge. Both the areola and nipple have chronic, moist eczematous changes. Paget's disease is estimated to occur in 1 to 2 percent of breast cancers.4 Most cases are diagnosed in postmenopausal women. Unfortunately, early...

Mercuryinduced immune systemrelated disease in humans

Allergic contact dermatitis is a well-established complication of mercury exposure. It may result from handling of metallic mercury and or topical administration of mercury-containing agents. Allergic contact dermatitis has also been described in persons exposed to mercury-containing antiseptic solutions, cosmetics or eye drops, or following inhalation of mercury vapour. Allergic contact dermatitis to mercury appears to be one of several causes of the so-called baboon syndrome. Low amounts of mercuric chloride were shown to induce certain morphological changes in skin, such as glycogen deposition, appearance of lysosome-like bodies and electron-dense material in cells of the epidermis. In humans, mercuric chloride is a strong sensitizer but also a skin irritant, reducing its use in dermatological testing procedures. Oral lichen planus has been suggested to mirror existence of mercury-specific lymphocytes, as

Development of bifidobacteria in the intestine and beneficial effects

The importance of the microbiota composition may initiate in early infancy when maturation of the gut barrier functions and immune development occurs. A few studies suggest that infants that do not harbour bifidobacterial species or harbour decreased numbers may be more prone to rectal bleeding (Arvola et al., 2006), allergy (Furrie, 2005) and eczema (Mah et al., 2006). Very early administration of B. breve to low birth weight infants was shown to be useful in promoting the colonization of bifidobacterial and the formation of a normal intestinal microbiota (Schrezenmeir et al., 2004). In several other studies bifidobacterial supplementation modified the infant gut microbiota in a manner that appeared to alleviate allergic inflammation (Kirjavainen et al., 2002) and reduced the incidence of acute diarrhoea and rotavirus infections (Saavedra et al., 1994). Also combinations of bifidobacterial species with Streptococcus thermophilus strains reduced the incidence of rotavirus associated...

Clinical Features

Other common disorders to be included in the differential diagnosis include candidiasis, erythrasma, lichen simplex chronicus, allergic and irritant contact dermatitis, and extramammary Paget's disease. A more extensive list of inflammatory processes of the intertriginous areas can be found in T.a.bl e 24.0.- 1 See the description under intertrigo for a comparison of the features of these disorders.

Contact Vulvovaginitis

Contact dermatitis results from the exposure of vulvar epithelium and vaginal mucosa to a primary chemical irritant or an allergen. In either case, characteristic local erythema and edema occur. Severe reactions may progress to ulceration and secondary infection. Common irritants and or allergens include chemically scented douches soaps bubble baths deodorants perfumes, dyes, and scents in toilet paper, tampons, and pads feminine hygiene products topical vaginal antibiotics and tight slacks, pantyhose, and synthetic underwear. Diagnosis of contact vulvovaginitis is made by ruling out an infectious cause and by identifying the offending agent. Most cases of mild vulvovaginal contact dermatitis resolve spontaneously when the causative agent is withdrawn. For patients with severe, painful reactions, cool sitz baths and wet compresses of dilute boric acid or Burow's solution may afford relief. Topical corticosteroids, such as hydrocortisone acetate, fluocinolone acetonide, or...

Autoimmune bullous dermatoses

Eosinophilic granulocytes and mast cells are thought to be important in bullous pemphigoid. Proteolytic enzymes derived from eosinophils, such as metalloproteases (gelatinase), may be involved in destruction of components of the BMZ. T cells have been implicated in the chronic stages of bullous pemphigoid and have been linked to the scarring in cicatricial pemphigoid (especially of the conjunctivae). Neutrophilic granulocytes and T cells have been implicated in the pathogenesis of dermatitis herpetiformis and in linear bullous IgA disease. Acquired epidermolysis bullosa seems to have a spectrum in which neutrophils play some role in certain subtypes but none in others. Finally, in the pemphigus group, evidence for a role of cellular mechanisms is generally lacking.

Diagnostic Tests Skin Prick Tests

Skin prick tests are mainly used in research studies. The results of skin tests cannot be taken alone, and standard textbooks on allergy acknowledge that ''the proper interpretation of results requires a thorough knowledge of the history and physical findings.'' The problems in clinical practice are, for example, whether or not a subject with atopic disease (eczema, asthma, or hay fever) or symptoms suggestive of food intolerance will benefit from attempts to avoid certain foods or food additives. However, skin prick test results are unreliable predictors of response to such measures.

Immunotherapy of autoimmune bullous dermatoses

Pemphigus and pemphigoid are primarily treated with high doses of oral prednisone, up to 200 mg per day. In limited cases, topical steroids may be given a try. In pemphigoid, a combination of tetracyclines and niacinamide has been shown to have good results and this combination might be given a try before deciding to give systemic steroids. Azathio-prine is given as a corticosteroid-sparing drug in prednisone-treated patients. Other systemic drugs used are cyclophosphamide and cyclosporine. The IgA-mcdiated diseases dermatitis herpetiformis and linear IgA disease, the rare bullous variant of SLE and IgA pemphigus respond to treatment with dap-sone or the sulfonamides sulfapyridine and sulfamethxypyridazine.

Type V hypersensitivity

See also Acute inflammatory reaction Allergens Anaphylatoxins Antiglobulin (Coombs') test Arthus reaction Atopic allergy Autoimmune diseases Blood transfusion reactions Cell-mediated immunity Contact hypersensitivity Delayed-type hypersensitivity Eczema Food allergy Granuloma Hemolytic disease of the newborn Immune complexes Rhinitis, allergic Sarcoidosis.

Thymic peptides as immunoregulators or biological response modifiers

TPs have been used clinically as antiviral agents and in the immunotherapy of cancer. TP5 is a highly effective drug as an antiviral therapy in recurrent herpes simplex, herpes zoster and human papilloma virus infection, reducing the relapse rate. It has also been shown to be a safe and effective adjunct to therapy in patients with severe atopic dermatitis, in which it decreases the release of polymorphonuclear leukocyte-derived inflammatory mediators. TP5 is able to produce consistent clinical and immunological effects in melanoma patients with cutaneous metastases, and is a potentially useful agent in the treatment of a subgroup of patients with Sezarv syndrome.

Implications of study design

Cohort studies are important in identifying risk factors for food allergy. This risk is usually quantified using odds ratios or relative risks. Confounding can still occur where a third factor may account for a perceived association between a particular exposure and an allergic outcome. Where such confounding variables are suspected and identified, their effects can be eliminated by the application of statistical methods such as logistic regression analysis. An example is the association seen between prolonged breast feeding and food allergy. This is not a real association as it is confounded by eczema infants with eczema are deliberately breast fed for longer periods and eczema is a known risk factor for food allergy.

Immunological markers

Puzzlingly also showed that an elevated cord blood total IgE was a significant protective factor for early-onset atopic eczema (Edenharter et al. 1998). Thus, cord blood total IgE is an unhelpful marker in predicting the development of food allergy and in planning appropriate prevention strategies.

Maternal intervention

Less eczema in Eczema Using eczema as the endpoint, which of course may or may not be associated with adverse food reactions, a number of studies in atopic populations using maternal dietary restriction during lactation alone (Chandra et al. 1989, Lovegrove et al. 1994, Hattevig et al. 1996) or during the last trimester of pregnancy and lactation (Chandra et al. 1986) have shown a reduction in eczema. The protective effect lasts for between 18 months and four years, with no effect being seen on ten-year follow-up (Hattevig et al. 1996). Not all the studies are randomised, and two of the studies have an unusually high prevalence of eczema in the control (no dietary restriction) population (Chandra etal. 1986, Lovegrove etal. 1994). In conclusion there is no consistent evidence to support maternal pregnancy dietary restriction in an attempt to reduce the risk of adverse food reactions. This is not surprising given the studies showing an absence of specific IgE to foods in cord blood...

Other Selected Mycotoxins

Sporidesmines, a group of hepatotoxins discovered in the 1960s, are also worthy of mention. These mycotoxins, causing facial eczema in animals, are produced by Pithomyces chartarum and Sporidesmium chartarum and are very important economically to the sheep industry. Slaframine, a significant mycotoxin produced by Rhizoctonia leguminicola (in infested legume forage crops), causes excessive salivation or slobbering in ruminants as a result of blocking acetylcholine receptor sites (CAST 2003).

Erythema multiforme and toxic epidermal necrolysis

Contact dermatitis Papulocrusting dermatitis, toxic epidermal necrolysis Contact dermatitis Contact dermatitis Contact dermatitis Crusts, caseous paronychia Toxic epidermal necrolysis Toxic epidermal necrolysis Contact dermatitis The immune mechanisms involved in contact dermatitis are assumed to include delayed type IV hypersensitivity reactions, in contact allergy, to be distinguished from contact irritant dermatitis where there is direct damage to epidermal keratinocytes. In either situation contact dermatitis appears to be rare in cats. Contact irritant dermatitis may range from epidermal oedema to a chemical burn, and could be associated with acids, alkalis, surfactants, solvents and so on. Contact allergens are poorly determined in veterinary dermatology and are assumed to involve low molecular weight lipid-soluble molecules that can act as haptens. The histopathological findings in contact dermatitis may be indistinguishable between irritant and allergic. The latter may involve...

Scabies Feces Pictures

The diagnosis is based on a high clinical suspicion and a positive scabies preparation. The diagnosis should be entertained when more than one family member itches. Other disorders to consider in the differential diagnosis include other bite reactions, body lice, atopic dermatitis, neurotic excoriations, and delusions of parasitosis. Suspected cases of scabies should be confirmed by performing a scabies preparation. To perform a scabies preparation, one scrapes or superficially shaves a lesion (preferably a burrow) with a 15 blade. The sample is placed on a glass slide, covered with immersion oil and a cover slip, and examined under the microscope. Mites, eggs, or scybala (feces) will be visible ( Hg , ). When possible, the diagnosis should be confirmed with a scraping prior to treatment.

Principal Mechanisms and Pathophysiology of Food Intolerance

The term 'allergy' implies a definite immunological mechanism. This could be antibody mediated, cell mediated, or due to circulating immune complexes. The clinical features of an allergic reaction include urticaria (nettle rash), angioedema, rhinitis (sneezing, nasal discharge, blocked nose), worsening of pre-existing atopic eczema, asthma (wheezing, coughing, tightness of the chest, shortness of

Mechanisms of the skin immune response

The elicitation phase of the contact allergic response is less well understood. Probably, allergen is taken up by local antigen-presenting cells, such as epidermal or dermal dendritic cells, which activate allergen-specific T cells that have settled in the skin after sensitization. Upon activation these cells produce mediators, allowing the further entry of circulating contact allergen-specific T cells. Various chronic inflammatory skin diseases are associated with infiltrates of CD4+ T cells. Whereas allergen-specific CD4+ T cells have been identified in contact allergy and constitutional eczema, the antigen-specificity of the CD4' T cells in diseases such as psoriasis and pityriasis rosea are unknown. See also Antigen-presenting cells CD1 Contact hypersensitivity Cutaneous anaphylaxis Delayed-type hypersensitivity Eczema Innate immunity Langerhans cells Photoimmunoiogy Skin, autoimmune diseases.

Muscle antigens Smooth muscle

Autoantibodies to endomysial membranes, the outside lining of smooth muscle bundles, are found in patients with dermatitis herpetiformis and with celiac disease, and are primarily IgA. The major test is IIF using the lower part of monkey esophagus as tissue substrate. It appears to be a more specific and sensitive marker of celiac disease than testing for reticulin autoantibodies. In a few patients with celiac disease that have an IgA immunodeficiency, the antibody to endomysial antigens were found to be IgG. Isotype-specific anti-immunoglobulins conjugated to FITC are used as specific reagents to determine the relevant autoantibodies.

Ophthalmic Surgery Cataract Surgery

Cataracts may be congenital, traumatic, steroid- or radiation-induced, or degenerative. In degenerative cataracts there will also be other medical conditions of the ageing population. While diabetics have no more cataracts than the general population, they tend to present earlier and so there seems to be a preponderance of diabetic patients presenting for cataract surgery. Steroid induced cataracts present in patients taking long term steroids for other conditions, particularly eczema or asthma which should be taken into account. Cataract surgery demands a still eye with low intra-ocular pressure. This can usually be achieved by smooth anaesthesia with muscle relaxation and IPPV to achieve mild hypocapnia, whether via a tracheal tube or laryngeal mask, though the latter is preferable because of the lack of intubation pressor response or laryngeal spasm and coughing on extubation. There is a fashion for local anaesthesia for cataract surgery despite this having a higher failure rate,...

Contact Hypersensitivity

Such as viruses, fungi and parasites (ticks and mites), that invade the skin however, there is also a response to environmental substances that enter the skin, causing the clinical condition of allergic contact eczema dermatitis. See also Antigen, entry into the body Antigen-presenting ceils Antigen presentation via MHC class II molecules Mast cells Cell-mediated immunity Delayed-type hypersensitivity Eczema Hapten Friedmann PS (1989) The immunology of allergic contact dermatitis the DNCB story. In Dahl MV (ed) Advances in Dermatology, 5th edn, pp 175-195. Chicago Year Book-Medical. Walker FB, Smith PO and Maibach HI (1967) Genetic factors in human allergic contact dermatitis. International Archives of Allergy and Applied Immunology 32 453-462.

Live recombinant vaccines

Live Recombinant Vaccines

However, vaccinia is not an ideal candidate vector for human vaccines. Despite its widespread use in the smallpox eradication campaign, it is not a very safe vaccine for example, it is not suitable for people with skin conditions such as eczema, nor for people who are immunodeficient. However, there are

Vitamin B2 Riboflavin

Vitamin B2 (riboflavin) works as an antioxidant through its activity in the formation of glutathione reductase and glutathione. As a part of the group of enzymes called flavoproteins, it is involved in the metabolism of fats, proteins, and carbohydrates. It is not stored in appreciable quantities in the body and must be replenished daily. Vigorous exercise increases the daily requirement of riboflavin, and a deficiency results in cracked lips, reddened tongue, and eczema of the face and genitals. The average daily adult requirement is 1.7 mg.1

Bare lymphocyte syndrome type II

Tion responses without immunosuppression, presumably because class I antigens are expressed by these patients along with, in some cases, low levels of class II molecules. Thus, the success of bone marrow transplantation is reduced in these individuals compared with other patients suffering from combined immunodeficiencies. Total numbers of peripheral blood T cells are normal in BLS type II patients, with very low numbers of circulating CD4+ T lymphocytes and enhanced levels of CD8+ T cells. This observation differs from the phenomena observed in mice lacking class II structural genes, where no single positive CD4 T cells mature. Possible explanations may include low expression of class II antigens on thymic cells in BLS type II patients, resulting in limited CD4* T cell selection. Alternatively in humans, class I molecules in the thymus may play a role in the selection of CD4+ T cells. Most interestingly, following bone marrow transplantation of these patients, the circulating levels...

Food Intolerance and Allergy

Usually, individuals prone to food allergies suffer only a few symptoms. Symptoms can vary among individuals, ranging from the common gastrointestinal symptoms to severe anaphylaxis. Table 10.4 summarizes the symptoms experienced during allergic reactions to foods. Rhinitis is runny nose, asthma is difficulty breathing, laryngeal edema is constriction of the throat, angioedema is swelling, urticaria is hives, and eczema atopic dermatitis is skin rash. The potentially fatal form of food- Laryngeal edema Eczema atopic dermatitis Nausea

Effects on Particular Organs or Organ Systems

The skin suffers toxic effects itself, including cancer, primary irritation, allergic reactions, hair loss, pigment disturbances, ulceration, and chloracne. Dermatitis is an inflammation of the dermis. Irritant contact dermatitis and allergic dermatitis can both be caused by exposure to chemicals and produce similar symptoms, including hives, rashes, blistering, eczema, or skin thickening. The difference between them is that a true allergy takes time to develop, typically at least two weeks whereas irritation does not require a previous exposure. For example, no one reacts to poison ivy when first exposed. Only after a second or subsequent exposure does the itchy rash develop. Common causes of ulceration include acids and burns. In addition, contact with cement and chromium-containing materials are well known to cause skin ulcers. The latter includes leathers that have been tanned with chromium compounds. Chloracne is an disease characterized by acute formation of an acnelike skin...

Biological functions of IgE

On the whole, allergy is a concern in the more highly industrialized parts of the world, where immunology is mainly practised and where intensive efforts are being made to understand the 'pathogenesis' of allergy. Allergic conditions include hayfever or rhinitis (the most common), asthma, atopic dermatitis, food allergy and allergic uveitis (affecting the eyes). Anaphylactic shock is the only manifestation of the response that is systemic in nature, and thus differs from the others, which predominantly affect single organs. There has been an alarming increase, corresponding to a 10-year doubling rate, in the incidence of allergic disease in the industrialized parts of the world over the last few decades. Now one in five adults suffers from some form of allergy and a similar proportion of children suffer from asthma. IgE is implicated in the pathogenesis of allergy, as a key component in both the afferent (by way of dendritic cells and B cells) and the efferent (by way of mast cells...

Acute Cutaneous Lupus Erythematosus

Diagnosis is based on clinical examination and the presence of other systemic symptoms suggestive of SLE. This eruption is by no means specific for lupus erythematosus. The differential diagnosis includes rosacea, erysipelas, dermatomyositis, seborrheic dermatitis, medication-induced photosensitivity, polymorphous light eruption, and allergic contact dermatitis. Skin biopsy may be helpful especially if the diagnosis is in question. Initial laboratory evaluation includes a complete blood count, chemistry profile to include BUN and creatinine, urinalysis with evaluation of urine sediment, antinuclear antibodies, double-stranded DNA, and complement.

TABLE 1872 Risk Factors for Serious Heat Injury Heatstroke

By diminishing sweating ability, many skin diseases can decrease the ability to disperse heat. Scleroderma, cystic fibrosis, eczema, psoriasis, and burns decrease sweating ability. Congenital diseases, such as ectodermal dysplasia, involving the sweat glands increase risk of heat injury. Interestingly, even the presence of simple heat rash has been shown to decrease sweating. Histologic studies of skin with heat rash have demonstrated obstruction of sweat gland ducts by keratin debris, resulting in significantly lower sweating rates and decreased tolerance time in a hot environment. 13

Novel and uncommon food allergies

Table 10.12 makes the point that uncommon food allergens are important causes of food allergy in specific countries. In an Israel allergy clinic population, sunflower seed was responsible for 22.3 of 112 positive food challenges in subjects between 10 and 48 years of age (Kivity et al. 1994). In Singapore, out of 124 consecutive admissions with anaphylaxis, the commonest cause was bird's nest soup (Goh et al. 1999), a food not implicated in allergy elsewhere in the world. In Japan rice appears to be a relatively common cause of allergy causing atopic eczema, although more severe acute reactions to rice are rare (Ikezawa et al. 1992). Rice is also a common cause of food allergy in Thailand (Hill et al. 1997). Adverse reaction to buckwheat is a common problem in Japan. In a population of 92,680 schoolchildren in Japan, the incidence of adverse reaction to buckwheat on questionnaire was 0.22 (Takahashi et al. 1998). The risk of anaphylaxis to buckwheat was higher than for egg and milk....

Pharmacological Uses and Toxicity of Vitamin B6 Supplements

Supplements have also been used empirically, with little or no rational basis, and little or no evidence of efficacy, in the treatment of a variety of conditions, including acute alcohol intoxication, atopic dermatitis, autism, carpal tunnel syndrome, dental caries, diabetic neuropathy, Down's syndrome, Huntington's chorea, schizophrenia, and steroid-dependent asthma.

Timing of Reaction and Delayed Reactions

Most allergic reactions to foods occur within minutes of ingestion of the food. However, sometimes a reaction may be delayed. This is best documented in cow's milk protein allergy, in which three types of reaction are recognized early skin reaction, early gut reaction, and late reaction. An affected individual usually exhibits only one of these types of reaction. In the early skin reaction group, symptoms begin to develop within 45 min of cow's milk challenge. Almost all patients in this group have a positive skin prick test to cow's milk. In the early gut reaction group, symptoms begin to develop between 45 min and 20 h after cow's milk challenge. Approximately one-third of patients in this group have a positive skin prick test to cow's milk. In the late reaction group, symptoms begin to develop approximately 20 h after cow's milk protein challenge. Only approximately 20 of this late reaction group have a positive skin prick test to cow's milk, and these are mostly children with...

Characteristics of patients with food intolerance

Briefly, intolerance reactions are more common in adults and a wide range of responsible foods and symptoms induced are demonstrated.11,12 It must be remembered that not all IgE-mediated disease occurs immediately. There is a well-described phenomenon of late-phase IgE reactions with late urticaria (itchy hives) and oedema (swelling) within the first 24 hours of exposure to the foods. It can be difficult to distinguish clinically this 24-48 hour reaction from that which is caused by non-IgE-mediated immunological reactions such as those that cause an exacerbation of eczema. Often the temporal association with a dietary exposure to allergen is the only clue.

Immunodeficiency Animal Models Of

Wiskott-Aldrich syndrome is the result of a mutation in human WASP, a proline-rich protein involved in regulation of the actin cytoskeleton and possibly also tryosine kinase-dependent cell signaling events. Together, the scurfy and xid mutants share some phenotypic features with this syndrome which is characterized by impaired responses to polysaccharide antigens along with eczema and platelet abnormalities.

Idiopathic Scrotal Edema

Acute idiopathic scrotal edema (AISE) is a fairly common, yet underreported cause of the acute scrotum in children, accounting for as many as 30 of patients who undergo assessment (Najmaldin and Burge 1987). It is characterized by the rapid onset of nontender, frequently unilateral scrotal and penile erythema and edema. The patient is usually afebrile and is otherwise asymptomatic, apart from the distressing appearance of the genitalia. It is usually found in prepubertal children from 5 to 11 years of age. As the name implies, the cause of AISE is unknown however, some children present with a history of asthma or allergic conditions such as eczema or dermatitis (Klin et al. 2002). Laboratory investigations are usually normal, with occasional

Occupation and smoking

Respiratory diseases have known associations with those working in the food and food-related industries. These include occupational asthma, occupational rhinitis and hypersensitivity pneumonitis. Skin diseases such as contact dermatitis and contact urticaria are also associated with work in these industries. These diseases are not all Type I, IgE-mediated reactions. Some cases of occupational asthma and some of contact dermatitis occur as a result of irritation.12 Hypersensitivity pneumonitis occurs as a result of a Type III or possibly a Type IV hypersensitivity reaction.13 As with non-industrial food allergy or intolerance, the pathophysiological mechanism affects the choice of diagnostic tests.

Tests for Circulating IgE Antibodies the Radioallergosorbent RAST Test

The radioallergosorbent (RAST) test is the best known of a number of laboratory procedures for the detection and measurement of circulating IgE antibody. Unfortunately, the clinical interpretation of RAST test results is subject to most of the same pitfalls as that for skin prick testing. Additional problems with RAST tests are the cost, and the fact that a very high level of total circulating IgE (e.g., in children with severe atopic eczema) may cause a false-positive result. Depending upon the criteria used for positivity, there is a fair degree of correlation between the RAST test and skin prick test results.

Dairy products and probiotics in childhood disease

Kalliomaki et al. investigated the long term effect of early colonisation of infants with probiotic bacteria on allergy prevention. One hundred and fifty-nine pregnant women who had a positive family history for atopy were supplemented during their last month of pregnancy with L. rhamnosus GG. Probiotic administration was continued in mothers and children for six months after delivery. The primary end point was chronic atopic eczema. Probiotic treatment led to a significant reduction in the prevalence in at-risk infants at the age of two years (46 versus 23 ) (Kalliomaki et al., 2001b). However, there was no decrease in antigen-specific IgE by L. rhamnosus GG administration. The authors performed a four-year follow up of the study group. Sixty-seven percent of the initially randomised children were reexamined. In the probiotic supplemented population there was a significantly decreased prevalence of atopic eczema compared with the non-treated group (14 of 53 versus 25 of 54 children)...

Intervention strategies aimed at preventing adverse food reactions

Most of the work in this area has been directed at preventing allergic sensitisation (primary prevention), rather than the prevention or suppression of clinical disease once sensitisation has occurred (secondary and tertiary prevention respectively). Up to now, no therapy has been shown to be of value in secondary or tertiary prevention of adverse food reactions. Furthermore, whilst some studies show that pharmacological intervention may alter the incidence and natural history of asthma, there are no comparable data regarding adverse food reactions (Bustos et al. 1995, Warner 1997). This section therefore concentrates on the dietary intervention studies set up with the aim of preventing or reducing the occurrence of adverse food reactions. Some of the studies look at children with a high risk of atopy (usually defined as those children with at least one first-degree relative with documented atopic disease), others at unselected children from the general population. Most do not focus...

Curing Eczema Naturally

Curing Eczema Naturally

Do You Suffer From the Itching, Redness and Scaling of Chronic Eczema? If so you are not ALONE! It strikes men and women young and old! It is not just

Get My Free Ebook