Topical Regimen Research Articles

Randomized Controlled Trial of Advice on an Egg Exclusion Diet inYoung Children with Atopic Eczema and Sensitivity to Eggs

Lever R, MacDonald C, Waugh P, Aitchison TPediatr Allergy Immunol.919981319The role of exclusion diets in the management of atopic dermatitis (AD) in young children remains controversial. The aim of this randomized, controlled trial was to evaluate the effect of excluding egg from the diet in young children with AD and sensitivity to eggs.Fifty-five children with AD and egg sensitivity were randomized either to a 4-week egg exclusion diet (diet group, n = 28) or no diet (control, n = 27). The mothers of all children were given advice on the general care of eczema. Randomization for the dietary phase took place only after optimal control of the eczema was achieved and the child was stable on maintenance treatment (mean = 3.5 months). Disease activity was assessed by estimates of the surface area affected by eczema and by an arbitrary severity score. Possible egg sensitivity was identified by radioallergosorbent test (RAST) before randomization and after the trial by double-blind, placebo-controlled egg challenge.Overall, two thirds of the children with positive RAST results to egg experienced a positive reaction during double-blind challenge. After the dietary period, the dietary group experienced a significantly greater mean reduction in surface area affected by eczema than the control group (P = .02); from 19.6% to 10.9% area affected in dietary group compared with the 21.9% to 18.9% reduction in the control group. A significant improvement also was seen in the severity score (P = .04); from 33.9 to 24.0 units for the dietary group compared with a decrease from 36.7 to 33.5 in the control group. Egg-sensitive patients in the control group were then placed on a 4-week egg exclusion diet and also showed significant improvement in their severity scores.The authors concluded that advice on the dietary exclusion of eggs is useful as part of the overall management of young children with atopic eczema and sensitivity to eggs.Allergists and dermatologists continue to disagree over the role of allergic inflammation in children with AD. A recent study demonstrated that almost 40% of children presenting to a university dermatology clinic with moderate to severe AD have food hypersensitivity (see below). This study by Dr Lever and her dermatology colleagues demonstrates that removal of a food allergen from the diet of a food allergic patient leads to improvement in eczematous symptoms. In fact, it is somewhat remarkable that significant differences were observed in this relatively small number of patients, in such a short period of time, with the exclusion of a single food after an intensive topical steroid regimen. It would have been interesting to see whether a more complete dietary assessment and longer follow-up would have produced even more striking results, and information on whether a significant reduction in medication requirements occurred in the dietary group.

Photodynamic therapy utilising topical delta-aminolevulinic acid in non-melanoma skin malignancies of the eyelid and the periocular skin.

Photodynamic therapy utilising delta-aminolevulinic acid-induced protoporphyrin IX photosensitisation, was evaluated as a treatment modality for nonmelanoma skin malignancies of the eyelids and the periocular skin. Photodynamic therapy with laser light at 635 nm was performed in 13 patients with 19 basal cell carcinomas and one patient with 3 cutaneous T-cell lymphoma lesions. A topical application regimen was used and in median 3 treatment sessions were given to each lesion. A visually judged complete response was achieved in 42% (8/19) of the basal cell carcinomas and in 100% of the T-cell lymphoma lesions (3/3). Partial tumour response was seen in 42% (8/19) and no response in 16% (3/19) of the basal cell carcinomas. The median follow-up time was 12 months. No, or very little scarring and loss of cilia were induced by the treatment. Photodynamic therapy with delta-aminolevulinic acid can eradicate eye-close non-melanoma skin malignancies without compromising the function of the eyelids. Further development of the method is needed to reach the same cure rates as those of the conventional treatment modalities.

Prophylactic antibiotics in patients undergoing laser resurfacing of the skin

Background: Carbon dioxide (CO 2 ) laser resurfacing produces a superficial second-degree burn that needs to be protected from bacterial and fungal infections. Objective: We investigated the effects of various systemic and topical antimicrobial regimens. Methods: Four different regimens using oral ciprofloxacin, topical antibiotics (intranasal mupirocin ointment and otic solution), oral ketoconazole, and oral fluconazole were tested in four time periods. The frequency and types of the infections with various regimens was compared. Results: The study included 356 sequential patients who underwent facial CO 2 laser resurfacing. Infections occurred in 27 patients (7.6%). Without antibiotic prophylaxis, 8.2% of patients had bacterial infections from days 3 to 12 after the procedure (average, day 5). With prophylactic ciprofloxacin only, 4.3% of patients had bacterial infections; these occurred almost exclusively after ciprofloxacin was discontinued. For 7 months, patients were randomly assigned to either receive or not receive mupirocin intranasally. All Staphylococcus aureus infections that occurred were seen in patients who had used intranasal mupirocin. Yeast infections were seen in 6 patients (1.7%), but mostly occurred more than 10 days after the procedure. Yeast infections were of approximately equal occurrence in the ciprofloxacin group (2.2%) and in the non-ciprofloxacin group (1.8%). No yeast infections occurred in patients who had undergone antifungal prophylaxis. Conclusion: Post-CO 2 resurfacing infections are not rare but can appear subtly and might only be noticeable in the second postoperative week. Prophylactic intranasal mupirocin is ineffective, but ciprofloxacin is effective in preventing infection with both gram-positive and gram-negative bacteria. Oral ketoconazole and fluconazole are effective in preventing yeast infections. (J Am Acad Dermatol 1999;40:77-84.)

Changing bacterial ecology during a five year period of selective intestinal decontamination

The development of bacterial resistance during selective decontamination of the digestive tract (SDD) is controversial. We studied effects on bacterial resistance one year before and during a randomized, placebo-controlled trial of SDD in a surgical intensive care unit. We randomized patients within two different topical regimens (PTA, PCA) or placebo, administered four-times daily to both the oropharynx and gastrointestinal tract. All patients received intravenous ciprofloxacin (200 mg b.d.) for four days. Both SDD regimens successfully reduced aerobic Gram-negative intestinal colonization. There was no increase in resistance of Enterobacteriaceae or Pseudomonas aeruginosa. Acinetobacter calcoaceticus developed multi-resitance over one year, but differences between groups were not significant. We detected a shift towards Gram-positive organisms. Oxacillin-resistant Staphylococcus aureus increased in concert with ciprofloxacin resistance, from 17 to 80·7%, and frequencies of resistance were significantly higher in SDD patients ( P < 0·001). Resistance of coagulase-negative staphylococci (CNS) to oxacillin increased initially (25 to 66·9%), but values returned to baseline in controls. Ciprofloxacin resistance in CNS remained higher ( P < 0·001) in SDD-treated patients (52·5 vs. 23·3%). The incidence of late respiratory tract infections was unaltered by the prophylactic regimen (SDD 35·2%; Placebo 41·2%; n.s.). We cannot recommend SDD as a prophylactic tool in critically ill patients.

Effects of a low-potency corticosteroid lotion plus a moisturizing regimen in the treatment of atopic dermatitis

Treatment goals for atopic dermatitis consist of attempting to eliminate inflammation and infection, hydrating the skin, controlling pruritus, and avoiding exacerbative factors. The aim of this study was to evaluate the effects of adding a moisturizing regimen to a low-potency topical corticosteroid lotion regimen in the treatment of atopic dermatitis. This controlled, randomized, investigator-masked 3-week study was undertaken to compare twice-daily applications of desonide lotion 0.05% alone with twice-daily applications of desonide lotion 0.05% plus three-times-daily applications of a moisturizing cream. The efficacy variables assessed included erythema, dryness or scaling, pruritus, excoriations, lichenification, oozing or crusting, and induration or papules. Administration of desonide lotion alone created statistically significant improvement in total sign and symptom scores. The addition of a moisturizer to the treatment regimen produced additional statistically significant improvement in total sign and symptom scores, physicians' global assessments of improvement, and most of the individual efficacy variables. Results of this study suggest that the addition of a moisturizer to a low-potency corticosteroid lotion in separate regimens was effective in treating the signs and symptoms of mild-to-moderate atopic dermatitis.

Knemometry in Children with Atopic Dermatitis Treated with Topical Glucocorticoids

Abstract: Recently the knemometer, a lower leg length measuring device, has been introduced for sensitive assessment of systemic activity of exogeneous glucocorticoids in children. The aim of this study was to assess by means of knemometry whether the topical glucocorticoid budesonide affects short‐term growth in children with atopic dermatitis. Fourteen children 5 to 12 years old were studied in an open longitudinal trial with three periods of 2 weeks duration. In periods 1 (run‐in) and 3 (run‐out), the children were treated with emollient. In period 2, budesonide cream 0.025% was followed by emollient twice daily to all of the body except the face. Eczema was evaluated according to a score based on extent and activity. Knemometry was performed twice weekly. Compared to the run‐in and run‐out periods the mean growth rate during budesonide treatment was reduced by 0.11 mm/wk (p &gt; .05) and 0.40 mm/wk (p &lt; .05), respectively. The mean growth rate during run‐out was increased by 0.29 mm/wk as compared to run‐in (p &lt; .05). Compared to run‐in the mean severity indices during budesonide treatment and runout were reduced by 1.55 (p &lt; .05) and 1.55 points (p &lt;.05), respectively. The concomittant variations in lower leg growth rate and disease activity suggest that short‐term treatment with topical glucocorticoids may provide a better growth potential during the weeks after withdrawal of the treatment. Whether this is due to improved disease control needs further study. Being a noninvasive method, knemometry may be useful for comparing different topical glucocorticoids and administration regimens in children in whom vasoconstrictor assays are difficult.

Knemometry in children with atopic dermatitis treated with topical glucocorticoids.

Recently the knemometer, a lower leg length measuring device, has been introduced for sensitive assessment of systemic activity of exogeneous glucocorticoids in children. The aim of this study was to assess by means of knemometry whether the topical glucocorticoid budesonide affects short-term growth in children with atopic dermatitis. Fourteen children 5 to 12 years old were studied in an open longitudinal trial with three periods of 2 weeks duration. In periods 1 (run-in) and 3 (run-out), the children were treated with emollient. In period 2, budesonide cream 0.025% was followed by emollient twice daily to all of the body except the face. Eczema was evaluated according to a score based on extent and activity. Knemometry was performed twice weekly. Compared to the run-in and run-out periods the mean growth rate during budesonide treatment was reduced by 0.11 mm/wk (p > .05) and 0.40 mm/wk (p < .05), respectively. The mean growth rate during run-out was increased by 0.29 mm/wk as compared to run-in (p < .05). Compared to run-in the mean severity indices during budesonide treatment and run-out were reduced by 1.55 (p < .05) and 1.55 points (p <.05), respectively. The concomitant variations in lower leg growth rate and disease activity suggest that short-term treatment with topical glucocorticoids may provide a better growth potential during the weeks after withdrawal of the treatment. Whether this is due to improved disease control needs further study. Being a noninvasive method, knemometry may be useful for comparing different topical glucocorticoids and administration regimens in children in whom vasoconstrictor assays are difficult.

Glycolic Acid Peels for Postinflammatory Hyperpigmentation in Black Patients

Treatment of postinflammatory hyperpigmentation in patients of Fitzpatrick skin types IV, V, and VI is difficult. Glycolic acid peels are useful for pigment dyschromias in caucasians; however, there are no controlled studies examining their safety and efficacy in dark-complexioned individuals. To determine if serial glycolic acid peels provide additional improvement when compared with a topical regimen of hydroquinone and tretinoin. Nineteen patients with Fitzpatrick skin type IV, V, or VI were randomized to a control or peel group. The control group applied 2% hydroquinone/10% glycolic acid gel twice daily and 0.05% tretinoin cream at night. The peel patients used the same topical regimen and, in addition, received six serial glycolic acid peels (68% maximum concentration). Patients were evaluated with photography, colorimetry, and subjectively. Sixteen patients completed the study. Both treatment groups demonstrated improvement, but the patients receiving the glycolic acid peels showed a trend toward more rapid and greater improvement. The peel group also experienced increased lightening of the normal skin. This pilot study demonstrates that serial glycolic acid peels provide an additional benefit, with minimal adverse effects, for the treatment of postinflammatory hyperpigmentation in dark-complexioned individuals.

Preoperative preparation of the laser resurfacing patient

Proper preoperative preparation of the patient for laser skin resurfacing entails several steps. Of primary importance is patient education about the options, risks, and benefits of the procedure, the procedure itself, and the postoperative course. In addition, the skin may benefit from a topical regimen implemented before laser resurfacing. Finally, appropriate perioperative medications need to be prescribed, and patients should be educated about the required immediate postoperative wound care. Well-educated and prepared patients are less anxious, and procedures and recovery periods run more smoothly. Proper preoperative preparation of the patient for laser skin resurfacing entails several steps. Of primary importance is patient education about the options, risks, and benefits of the procedure, the procedure itself, and the postoperative course. In addition, the skin may benefit from a topical regimen implemented before laser resurfacing. Finally, appropriate perioperative medications need to be prescribed, and patients should be educated about the required immediate postoperative wound care. Well-educated and prepared patients are less anxious, and procedures and recovery periods run more smoothly.

Emollients as adjuvant therapy for psoriasis

Emollients are used very widely by patients with psoriasis because of their soothing properties and the important cosmetic aspect of reducing the scale. The scaling caused by psoriasis is a major contributing factor to the handicap experienced. It may be, however, that emollients not only have a physical action, but have an additional biochemical therapeutic action. Emollients may inhibit the Koebner phenomenon, and reduce the mitotic rate of stripped mouse skin. The addition of emollients to a topical steroid regimen for plaque psoriasis results in more rapid improvement. In an open within-patient study to assess the effect of E45 Cream when used as an adjunct to dithranol for the treatment of chronic plaque psoriasis, there was significant overall improvement at day 28, reduction in skin redness at days 7 and 28 and reduction in skin thickness at day 7 of the site treated with E45 Cream. Despite the relative paucity of evidence concerning the use of emollients in psoriasis, their value is widely accepted by patients and dermatologists.

Topical anesthesia for phacoemulsification: Initial 20-case series with one month follow-up

We report the results of our initial 20 phacoemulsification cases performed using topical anesthesia. The preferred topical regimen consisted of preservative-free 0.75% bupivacaine. Intravenous sedation was provided primarily with fentanyl and midazolam. Phacoemulsification was performed through a scleral tunnel incision, and a one-piece poly(methyl methacrylate) or three-piece silicone intraocular lens was implanted. There were no complications with the anesthetic technique. One day postoperatively, 69% of patients with a desired refractive error within 0.75 diopters of emmetropia had an uncorrected visual acuity of 20/40 or better. At one month, all patients had a best corrected acuity of 20/30 or better, and 60%, 20/20 or better. Eighteen patients reported complete intraoperative comfort, and 17 reported complete postoperative comfort. Seven of the 10 patients who had had previous peribulbar anesthesia preferred topical. All 10 “first eye” patients said they would choose topical anesthesia for future surgery. With appropriate case selection, topical anesthesia for phacoemulsification surgery can be used with excellent intraoperative and postoperative results.

The Cost of Topical Drugs for Dermatophyte Infections

To the Editor. —The recent article, A Cost Analysis of Topical Drug Regimens for Dermatophyte Infections, by Drs Chren and Landefeld, 1 which includes the available effective drugs fails to take into serious consideration what many know to be a quite effective topical remedy, especially for tinea versicolor as well as tinea pedis—sodium hypochlorite. This comes in a 5% solution as Clorox at $0.89 per gallon at your corner grocery store. It is used at one part Clorox to four parts of water for tinea versicolor and at slightly stronger concentrations for tinea pedis and onychomycosis.

Inability of two topical treatments to influence the course of experimentally induced dermatophytosis in cats

Summary An experimental model of dermatophytosis was used to compare the efficacy of 2 topical antifungal treatments against Microsporum canis infection in cats. Infection was established in 24 cats by topical application of 105 M canis macroconidia to the skin of the lateral part of the abdomen under an occlusive bandage. Three groups of 6 cats each then were treated twice weekly for 18 weeks with chlorhexidine shampoo and dip, detergent shampoo vehicle only, or glyceryl monolaurate shampoo. Six cats were left untreated as controls. The experimentally induced infections strongly resembled naturally developing infections of moderate to severe nature. Signs of infection peaked in severity at 5 weeks after inoculation, then gradually resolved over 7 to 16 additional weeks. Dermatophytes were consistently isolated on culture for at least 8 weeks of treatment. Mycologic cure (defined as lack of dermatophyte isolation on 3 successive weekly cultures) was attained in 8 cats at the end of 18 weeks of treatment. Infections appeared to resolve at equivalent rates in all groups of cats, including controls. Consistent or meaningful significant differences in variables such as lesion size, clinical sign score, or total infection score were not found between treated and control groups. Our study revealed that this topical treatment regimen with chlorhexidine or glyceryl monolaurate is ineffective against M canis infection in cats.

Evaluation of endoscopic topical therapy regimens of amoxicillin, bismuth subnitrate, and metronidazole in treating Helicobacter pylori (HP)

Evaluation of endoscopic topical therapy regimens of amoxicillin, bismuth subnitrate, and metronidazole in treating Helicobacter pylori (HP)

The efficacy of different umbilical cord care regimens: An in vitro study on their drying and antimicrobial effect: Jeng M.-J.; Soong W.-J.; Lau M.-C.; Chen S.-J.; Hwang B Chin Med J Taipei 1994 53/5 (293–297)

Topical regimens have been used for umbilical cord care for different purposes, but their drying efficacy has rarely been statistically analyzed. We designed an in vitro study with six regimens to determine which one can achieve the best drying and antimicrobial effects in umbilical cord care.Twenty-seven umbilical cords were resected when babies were born. Each cord was cut into seven segments in appropriate length and randomly labeled to seven groups. Six regimens including 75% alcohol, 90% alcohol, tincture povidone-iodine, aqua povidone-iodine, Chinese herbs, and one powder agent (M) were used topically on six groups of umbilical cords once daily. The control group received no treatment. Daily weight of the cords was recorded for 7 days, and bacterial culture was performed on the sixth day.All study groups presented similar algebraic functional relationship between weight change and time. The drying effect occurred mostly within the first 3 days (weight loss 88.6%), especially on the first day (62.1%). Mean ratio of the final weight/initial weight was 10.2%. Significant day-by-day weight loss was noted from day 1 to day 5 (p < 0.001). Both aqua and tincture povidone-iodine groups showed not only satisfied drying effect but also significantly better antimicrobial effect than other groups.Povidone-iodine has both good drying and antimicrobial effects in umbilical cord care. As the topical use of povidone-iodine has been reported to relate to transient neonatal hypothyroidism, we suggest it to be used only as a good substitute if there are signs of umbilical cord infection.

Treatment of HIV-related hairy leukoplakia with podophyllum resin 25% solution

Ten HIV-infected patients who had bilateral hairy leukoplakia on the tongue were treated with topical podophyllum resin 25% solution. Only one side of the bilateral lesion was treated and the other side served as the control and was not treated. The lesions on both the treatment and control sides were evaluated at day 2, 7, and 30 by an investigator who had not been involved in the initial treatment and had no knowledge of which side had been treated. Therefore the treatment side is compared with the control side in a single-subject design, single-blind control setting. The lesions were judged by the degree of resolution and assigned a number of 0 to 4 with 4 indicating the highest degree of resolution and 0 indicating no resolution or worsening of the condition. The results were analyzed by Student's t test. Significant resolution of hairy leukoplakia was noted on the treatment side compared with the control side at the 2-, 7-, and 30-day levels; the 2-day results were the most significant. Furthermore, the patients reported minimal side effects, which included burning sensation, bad or altered taste, and pain, that were of mild intensity and short duration. The side effects were reported to occur immediately after the topical application. Patient tolerance and acceptance were found to be very favorable. No systemic side effect was reported. We conclude that single topical application of podophyllum resin 25% solution is efficacious in producing significant short-term resolution of HIV-related oral hairy leukoplakia. We also conclude that it is a safe topical regimen with minimal side effects.

A cost analysis of topical drug regimens for dermatophyte infections

A cost analysis of topical drug regimens for dermatophyte infections

A Cost Analysis of Topical Drug Regimens for Dermatophyte Infections

To examine the extra cost of using higher-priced drugs as initial therapy for dermatophyte infections, because the many available effective drugs vary considerably in cost. Cost analysis from the purchaser's perspective, comparing two prototypical regimens to treat tinea pedis: one in which all patients initially receive a lower-priced drug and those with unresponsive infections receive a higher-priced drug at a follow-up office visit, and one in which all patients receive the higher-priced drug from the outset. The reference drug was miconazole, an imidazole available without a prescription, for which reported overall efficacy rates are 70% to 100%. The threshold efficacy rate (the efficacy rate of miconazole below which it is always less expensive to use a specific higher-priced drug first) and the extra cost (of beginning therapy with a higher-priced drug). Assuming the Medicare-approved charge for a follow-up visit ($21.98), it is less expensive to begin therapy with a prescription drug only if the efficacy rate of miconazole is less than 55%; this threshold efficacy rate varied from 26% (for a $0 total cost of the follow-up visit) to 79% (for an $89 total cost of the follow-up visit). If the efficacy rate of miconazole is 70%, the extra cost per patient for all patients to receive the least expensive prescription antifungal drug instead of miconazole first was $15.23 and $8.64 if total visit costs were $0 and $21.98; miconazole remained the less expensive alternative as long as the total cost of the follow-up visit was less than $50.76. For reported efficacy rates and standard costs of a follow-up office visit, using miconazole first and then treating only those patients with unresponsive infections with a higher-priced prescription drug is less expensive than treating all patients with the higher-priced drug.

Herpetic Eye Disease Study: A Controlled Trial of Topical Corticosteroids for Herpes Simplex Stromal Keratitis

To evaluate the efficacy of topical corticosteroids in treating herpes simplex stromal keratitis. The authors performed a randomized, double-masked, placebo-controlled, multicenter clinical trial of 106 patients with active herpes simplex stromal keratitis who had not received any corticosteroids for at least 10 days before study enrollment. Patients were assigned to the placebo group (n = 49) or the steroid group (topical prednisolone phosphate; n = 57); both regimens were tapered over 10 weeks. Both groups received topical trifluridine. Visual acuity assessment and slit-lamp biomicroscopy were performed weekly for 10 weeks, every other week for an additional 6 weeks or until removal from the trial, and at 6 months after randomization. The time to treatment failure (defined by specific criteria as persistent or progressive stromal keratouveitis or an adverse event) was significantly longer in the steroid group compared with the placebo group. Compared with placebo, corticosteroid therapy reduced the risk of persistent or progressive stromal keratouveitis by 68%. The time from randomization to resolution of stromal keratitis and uveitis was significantly shorter in the steroid group compared with the placebo group even though both groups included patients who were removed from the study and treated with topical corticosteroids according to best medical judgment. Nineteen (33%) of the steroid-treated patients and 11 (22%) of the placebo-treated patients completed the 10 weeks of protocol therapy and had stable, noninflamed corneas after 16 weeks. At 6 months after randomization, no clinically or statistically significant differences in visual outcome or recurrent herpetic eye disease were identified between the steroid and placebo groups. The topical corticosteroid regimen used in this study was significantly better than placebo in reducing persistence or progression of stromal inflammation and in shortening the duration of herpes simplex stromal keratitis. Postponing steroids during careful observation for a few weeks delayed resolution of stromal keratitis but had no detrimental effect as assessed by visual outcome at 6 months.

Adverse effects of topical antiglaucoma medication. I. The conjunctival cell profile.

To determine the effect of various long-term topical antiglaucoma regimens on the cell population profile of the conjunctiva. Conjunctival biopsy specimens from 124 patients undergoing filtration surgery were assessed quantitatively by light microscopy. Preoperatively, the patients had used a drug for only a brief period (group A; n = 28), a beta-blocker alone (group B; n = 31), a beta-blocker in combination with a miotic (group C; n = 33), or a combination of beta-blocker, miotic, and sympathomimetic (group D; n = 32). The conjunctiva in groups A and B was similar. Group C conjunctiva differed, but the changes were most marked in biopsy specimens from patients in group D, where there was a significant decrease in goblet cells (P < .05); increase in pale cells, macrophages, and lymphocytes within the epithelium (P < .001); and increase in fibroblasts (P < .001), macrophages (P < .001), mast cells (P < .05), and lymphocytes (P = .01) in the substantia propria. In addition, the effect of duration of therapy was assessed. Administration of topical medication for more than 3 years was found to increase the numbers of pale cells within the epithelium (P < .05); fibroblasts (P < .05), macrophages (P < .001), lymphocytes (P < .01), and mast cells (P = .001) within the superficial substantia propria; and the numbers of fibroblasts (P = .01) and macrophages (P < .05) within the deep substantia propria. The compared treatment regimens affected the conjunctiva to different degrees, with multiple-drug topical therapy exerting the greatest effect on the degree of subclinical inflammation within the conjunctiva. The results also indicated that administration of topical medication, irrespective of type, for 3 years or more induced a significant degree of subclinical inflammation.