News Forum

GPs with an interest in dermatology review the latest papers of significance from research teams across the world.

TREATMENT OPTIONS FOR THE MANAGEMENT OF ACNE VULGARIS
THE CHOICE OF WOUND DRESSINGS IN TREATING LEG ULCERS
THE EFFECTIVE TREATMENT OF CHRONIC OTITIS EXTERNA
NON-INVASIVE ASSESSMENT OF THE SEVERITY OF ATOPIC ECZEMA
DIET AND ACNE DEVELOPMENT
BETAPAPILLOMAVIRUS INFECTION AND ACTINIC KERATOSES
FRAGRANCE INGREDIENT LABELLING

TREATMENT OPTIONS FOR THE MANAGEMENT OF ACNE VULGARIS
Leyden JJ, Del Rosso JQ, Webster GF. Cutis 2007;79 (6 Suppl):9-25
This article from the US discusses the treatment options for acne vulgaris and other inflammatory skin disorders, looking mainly at the problem of antibiotic resistance. Propionibacterium acnes is an anaerobic bacterium that plays an important part in the pathogenesis of acne. Antibiotics can inhibit P acnes colonisation, leading to a reduction in inflammatory acne. However, the resistance of P acnes to certain antibiotics, such as erythromycin and tetracylines, is increasing, so these may no longer be effective.

Some antibiotics have an anti-inflammatory effect as well as antibacterial activity. This property can be useful in the treatment of acne, rosacea and other non-infectious skin diseases. Benzoyl peroxide is useful in the treatment of mild-to-moderate inflammatory acne. This non-antibiotic antibacterial agent is highly effective against P acnes; so far, no resistance to benzoyl peroxide has been demonstrated. Retinoids are effective against non-inflammatory acne (comedones). They are therefore useful in combination with other medications, especially antibiotics for patients with a combination of non-inflammatory and inflammatory acne. Retinoids also have a role as lone agents for maintenance therapy. The authors suggest that by increasing our understanding of the modes of action of antibiotics and the effects of antibiotic resistance, we can improve our management of acne vulgaris and other inflammatory skin disorders.
- Dr Waseem Chaudhry is a GPSI in dermatology in Caerphilly

THE CHOICE OF WOUND DRESSINGS IN TREATING LEG ULCERS
Palfreyman S, Nelson EA, Michaels JA. BMJ 2007;335 (7613):244
The choice of available wound dressings is vast, confusing and ever-increasing. Many dressings have come on to the market in recent years, with claims to be more effective in ulcer healing. The authors of this article reviewed the evidence of effectiveness of dressings applied to venous leg ulcers. They searched journals, electronic databases, conferences and bibliographies up to April 2006. Searches identified 254 trials looking at the effectiveness of dressings in venous leg ulcers. However, only 42 of these trials fulfilled the inclusion criteria. Data were extracted from the eligible trials by two independent reviewers and analysed.

Although some differences between dressings were found in terms of subjective outcome measures and ulcer healing rates, there was insufficient evidence to support the superiority of any one class of dressing. Hydrocolloids were no more effective than simple low-adherent dressings used under compression. Conclusions regarding the cost-effectiveness of different dressings could not be drawn, owing to insufficient data. The authors concluded that no recommendations could be made regarding which class of dressing to use. No class of dressing was objectively shown to be superior in the management of venous leg ulcers. Therefore, the decision on which dressing to apply should be based on cost, along with patient or practitioner preference. WC

THE EFFECTIVE TREATMENT OF CHRONIC OTITIS EXTERNA
Harth W, Caffier PP, Mayelzadeh B et al. Eur J Dermatol 2007;17(5):405-11
Chronic otitis externa can be a debilitating condition and often requires a multidisciplinary approach. This pilot study looked at the efficacy of topical tacrolimus ointment 0.1% in the management of chronic recalcitrant non-infective otitis externa that was resistant to other therapies. An interdisciplinary prospective study (involving dermatology and ENT specialists) of 53 patients with the condition was undertaken. Patients were evaluated for symptoms of otalgia, oedema, otorrhoea, erythema, pruritus and desquamation, on a six-point scale. Evaluations were undertaken before treatment, at the end of treatment and during follow-up of up to 22 months.

Short-term results showed a clinical improvement in 85 per cent of patients and a significant drop in severity scores for all clinical parameters. Long-term follow-up studies showed that one treatment cycle with topical tacrolimus led to complete remission in 46 per cent of patients. The remaining 54 per cent of patients continued to have recurrent otitis externa, but with longer symptom-free periods. No significant systemic side-effects were noted. The only local side-effects noted were occasional skin burning, stinging or irritation. This study shows that topical tacrolimus 0.1% ointment is an effective and well-tolerated treatment option for the management of treatment-resistant chronic recalcitrant non-infective otitis externa. The authors also commented that the dermatologist's knowledge and experience with topical immunomodulator therapy could be used in the treatment of inflammatory disorders in other medical specialties. WC

NON-INVASIVE ASSESSMENT OF THE SEVERITY OF ATOPIC ECZEMA
Holm EA, Wulf HC, Thomassen L et al. Br J Dermatol 2007 doi:10.1111/j.1365-2133.2007.08101.x
The author examines various ways of assessing the severity of atopic eczema currently used in clinical trials and research. These are divided into two groups: clinical scoring and non-invasive instrumental measurements. Clinical scoring methods assessed include Scoring of Atopic Dermatitis (SCORAD), Eczema Area and Severity Index (EASI) and Atopic Dermatitis Severity Index (ADSI). The non-invasive measurements include transepidermal water loss, stratum corneum hydration, erythema, scaling and sub-epidermal oedema.

The study compared clinical scoring with non-invasive instrumental measurements in atopic eczema to determine whether there is a positive correlation between the two. It involved two assessments at six-monthly intervals of set areas of atopic eczema, such as the antecubital fossa. A total of 101 patients with atopic eczema were assessed, with 30 controls. The findings were very positive, with significant correlation found within the three clinical scoring methods and between the clinical scoring methods and the non-invasive instruments. This is helpful data, supporting the use of clinical scoring and non-invasive measurements in assessing atopic eczema severity. These findings demonstrate the internal agreement of all the methods and this suggests, as the researchers conclude, that both methods provide data of clinical and biological relevance and could be particularly useful in future studies.
- Dr Jane Barnard is a GP with an interest in dermatology in Yateley, Hampshire

DIET AND ACNE DEVELOPMENT
Kaymak Y, Adisen E, Ilter N et al. J Am Acad Dermatol 2007 doi:10.1016/j.jaad.2007.06.028
This study explored the theory that a high glycaemic index diet can predispose a patient to acne. A small case-control study, involving 91 people (49 acne patients, 42 controls), evaluated a possible association between the development of acne and a high glycaemic index diet, glycaemic load and serum insulin level. The study involved an initial measurement of fasting glucose, insulin, insulin-like growth factor 1, insulin-like growth factor binding protein 3 and leptin levels. A self-completed questionnaire evaluated how frequently a patient consumed specific amounts of food and subsequent evaluation provided an overall glycaemic index and dietary glycaemic load.

There is a risk of recall bias here and the authors acknowledge this limitation. They conclude no significant differences in overall glycaemic index, dietary glycaemic load and glucose, insulin and leptin levels between patients with or without acne. However, caution should be exercised in concluding that diet does not play a part in the development of acne. In particular, the conclusion is limited by size of population, case-control design and use of a retrospective questionnaire, where recall bias may be a risk. This theory needs further research before we remove the advice to 'watch what you eat' in talking to acne patients. JB

BETAPAPILLOMAVIRUS INFECTION AND ACTINIC KERATOSES
McBride P, Neale R, Pandeya N, Green A. Arch Dermatol 2007;143:862-8
This study investigated whether betapapillomavirus influenced the development of actinic keratoses with or without sun exposure. Actinic keratoses are known to be strongly associated with squamous cell carcinomas. Betapapillomavirus has been detected in squamous cell carcinomas, basal cell carcinomas, actinic keratoses, hair follicle cells and healthy skin cells. This prospective cohort study involved a randomly selected population aged 36-86 years. A baseline assessment was carried out to establish betapapillomavirus DNA presence in eyebrow hair follicles. Subsequent sun exposure was documented in follow-up consultations and the prevalence of actinic keratoses determined.

The author concluded that beyond the known determinants of multiple actinic keratoses, (advanced age, male sex, fair skin and lifetime occupation sun exposure), betapapillomavirus infection was associated with having more than 10 actinic keratoses, demonstrating a small non-significant independent association. However, in conjunction with known risk factors, there was a 13-fold increase in the likelihood of actinic keratoses among those aged 60 years or more and a nearly sixfold increase in those with fair skin. The likelihood doubled in those who had the betapapillomavirus combined with high sun exposure. The authors conclude that the presence of the virus in eyebrow hair follicles enhances the effects of increasing age, fair skin and sun exposure, to increase the risk of developing actinic keratoses. Could identifying the betapapillomavirus reduce the incidence of actinic keratoses and, subsequently, of squamous cell carcinomas? Watch this space. JB

FRAGRANCE INGREDIENT LABELLING
Buckley DA. Br J Dermatol 2007;157:295-300
EU regulations require that cosmetic products and detergents must be labelled for 26 named fragrances, according to their concentrations. This study looked at 300 perfumed cosmetic and household products available in the UK and recorded any of the 26 listed fragrances named on the label. The researchers found that the most frequently labelled fragrances were linalool (63 per cent), limonene (63 per cent), citronellol (48 per cent), geraniol (42 per cent), butyl phenyl methyl propional (42 per cent) and hexyl cinnamal (42 per cent).Interestingly, 34 products contained none of the listed fragrances but were still labelled as containing 'parfum' or 'aroma'. The study found that there is an increase in consumer exposure to Evernia prunastri (oak moss absolute), isoeugenol and the cinnamon fragrances cinnamal and cinnamic alcohol, which are all considered to be the most frequent sensitisers. In the UK, the most frequent fragrances encountered by consumers are linalool and limonene. JB


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