Atopic dermatitis, and the role for a ceramide-dominant, physiologic lipid-based barrier repair emulsion.

Over the last half century, and especially over the last 15 years, understanding of the structure and function of the stratum corneum has evolved tremendously. Once conceptualized as an inactive film formed by lifeless, disintegrating keratinocytes, the stratum corneum is now recognized as a viable, functional structure that plays an important role in maintaining skin health and possibly mediating cutaneous diseases. Researchers and clinicians have also come to realize that the barrier functions not only to prevent the entry of exogenous factors, such as irritants or allergens, but that it also can mediate disease. We had already realized that dysfunction of the barrier may itself directly contribute to the pathogenesis of skin diseases, notably atopic dermatitis. More specifically, evidence shows that epidermal barrier dysfunction is likely to be a precursor of cutaneous inflammation.

Acne severity grading: determining essential clinical components and features using a Delphi consensus.

BACKGROUND: There are multiple global scales for acne severity grading but no singular standard. OBJECTIVE: Our objective was to determine the essential clinical components (content items) and features (property-related items) for an acne global grading scale for use in research and clinical practice using an iterative method, the Delphi process. METHODS: Ten acne experts were invited to participate in a Web-based Delphi survey comprising 3 iterative rounds of questions. RESULTS: In round 1, the experts identified the following clinical components (primary acne lesions, number of lesions, extent, regional involvement, secondary lesions, and patient experiences) and features (clinimetric properties, ease of use, categorization of severity based on photographs or text, and acceptance by all stakeholders). In round 2, consensus for inclusion in the scale was established for primary lesions, number, sites, and extent; as well as clinimetric properties and ease of use. In round 3, consensus for inclusion was further established for categorization and acceptance. Patient experiences were excluded and no consensus was achieved for secondary lesions. LIMITATIONS: The Delphi panel consisted solely of the United States (U.S.)-based acne experts. CONCLUSION: Using an established method for achieving consensus, experts in acne vulgaris concluded that an ideal acne global grading scale would comprise the essential clinical components of primary acne lesions, their quantity, extent, and facial and extrafacial sites of involvement; with features of clinimetric properties, categorization, efficiency, and acceptance.

A review of the safety and efficacy of benzoyl peroxide (5.3%) emollient foam in the management of truncal acne vulgaris.

This article reviews findings of studies regarding the treatment of truncal acne with benzoyl peroxide formulations and, in particular, studies utilizing a 5.3% benzoyl peroxide foam. Its formulation of micronized benzoyl peroxide particles in an emollient foam vehicle offers significant clinical and bioavailability advantages that enhance follicular penetration and skin moisturization. A key consideration for topical management of truncal acne is whether the treatment application method allows adequate skin contact time to reduce Propionibacterium acnes colony counts. The foam formulation has demonstrated significant reduction in Propionibacterium acnes on the back when used either as a leave-on or as short-contact therapy for five minutes. Short-contact therapy with a benzoyl peroxide foam is a novel approach to minimize the risk of benzoyl peroxide bleaching of clothing in truncal acne patients.

Case studies assessing a new skin barrier repair cream for the treatment of atopic dermatitis.

Atopic dermatitis (AD) is a common chronic inflammatory skin disease caused by a combination of genetic susceptibility, epidermal barrier dysfunction and immune dysregulation. The intense pruritus associated with the disease causes an itch-scratch cycle that worsens symptoms and can cause significant discomfort for the patient. Recently, the focus of the atopic dermatitis treatment paradigm has shifted from targeting inflammation to the use of agents that normalize the skin barrier, which may reduce the current dependence on topical steroids and immunomodulators. A new barrier repair cream (EpiCeram Skin Barrier Cream, Promius Pharma, Bridgewater, NJ) is a prescription topical agent indicated for the treatment of dry skin conditions and the relief of itching and burning associated with various dermatoses. This article describes the pathogenic rationale for using a barrier repair cream for the treatment of AD and discusses case report results focused on its clinical benefit for AD.

Facial seborrheic dermatitis: a report on current status and therapeutic horizons.

Seborrheic dermatitis, characterized by erythema and/or flaking or scaling in areas of high sebaceous activity, affects up to 5% of the US population and often appears in conjunction with other common skin disorders, such as rosacea and acne. Despite ongoing research, its etiology is puzzling. Increased sebaceous and hormonal (androgenic) activity is thought to play a part. Recent evidence suggests an important role for individual susceptibility to irritant metabolites of the skin commensal Malassezia, most probably M globosa. Current approaches thus include agents with antifungal as well as antikeratinizing, and anti-inflammatory activity. Azelaic acid, which has all 3 properties, may be a useful addition to first-line management, which now comprises of topical steroids, the immunosuppressant agents tacrolimus and pimecrolimus, azoles and other antifungals, and keratolytic agents. A recent exploratory study supports the efficacy and safety of azelaic acid 15% gel in seborrheic dermatitis. Azelaic acid may be especially valuable in this application because of its efficacy in treating concomitant rosacea and acne.

Demodex dermatitis: a retrospective analysis of clinical diagnosis and successful treatment with topical crotamiton.

Given the reported common occurrence of Demodex dermatitis in the general population, Demodex dermatitis-considered as a separate condition from rosacea and seborrheic dermatitis-was evaluated in a retrospective case analysis.

Benzoyl peroxide microsphere cream as monotherapy and combination treatment of acne.

This office-based case series describes the use of a new formulation of benzoyl peroxide (BPO) delivered via a porous microsphere cream vehicle in patients with mild to moderate acne vulgaris. While BPO has been used for many years as antimicrobial in the treatment of acne, in recent years its use has been increasingly encouraged as part of a strategy designed to reduce Propionibacterium acnes (P acnes) resistance to antibiotics. Historically, a major drawback to BPO treatment has been irritation, which may be concentration-dependent or vehicle-dependent. A new BPO microsphere cream formulation has recently been introduced and appears to offer favorable efficacy with a very low potential for irritation. This article presents a series of patients from 2 private dermatologic practices treated with a new BPO microsphere cream formulation both as monotherapy and in combination with other acne drugs.

Trolamine-containing topical emulsion: clinical applications in dermatology.

Trolamine-containing topical emulsion is used to promote and expedite wound healing. This agent has been shown to recruit macrophages, which serve important functions in the wound healing process, and increase the IL-1:IL-6 ratio, which enhances formation of granulation tissue and collagen synthesis. Therapeutic applications have included acute radiation dermatitis and postoperative wounds, and application after cryotherapy for actinic keratosis (AK). This article reviews the mechanism of action and information on clinical applications of trolamine-containing topical emulsion.

Hand eczema: diagnosis and management.

The most common clinical presentations of hand eczema are atopic hand dermatitis, pompholyx, and contact dermatitis (irritant contact dermatitis [ICD], allergic contact dermatitis [ACD]). The diagnosis of hand dermatitis is determined by a review of the patient's medical history, a physical examination including other body sites as well as the hands, and a thorough overview of the patient's daily activities with emphasis on occupation and hobbies. Irritant contact dermatitis usually is diagnosed by the absence of a positive patch test result; however, patch testing is essential in confirming a clinical diagnosis of ACD by identifying the allergens to which the patient has been sensitized. Treatment includes topical and/or systemic corticosteroids to reduce inflammation and ceramide-containing moisturizers to repair the skin's barrier function. Topical calcineurin inhibitors may be alternatives to topical corticosteroids. The most important step in the management of hand eczema is prevention with physical protective products (e.g., gloves) or barrier protection creams.

A new approach to comparing efficacy results from clinical trials of topical acne vulgaris treatments.

Clinicians must evaluate a voluminous amount of information from clinical trials when choosing among the growing number of topical acne treatments. This article describes a simple way to evaluate and broadly compare the efficacy results of well-controlled phase III clinical trials of topical acne treatments by taking into account the placebo effect (or active control effect). Key efficacy results are drawn from the package inserts of 7 primary topical acne treatments. To account for placebo effect, the mean percent reduction with placebo was subtracted from that of the active treatment for each type of lesion and also calculated as an average of these differences for all lesions. Based upon the principles of research, this method accounts for within study variances and offers a quick assessment of product efficacy. Clinicians should be cautioned that this method only allows for broad comparisons and does not establish definitive differences between treatments.

A closer look at truncal acne vulgaris: prevalence, severity, and clinical significance.

Data is very limited on the demographics, epidemiology, grading, and management of truncal acne vulgaris. In this study completed in 5 cities across the US, 696 patients were assessed to evaluate the frequency and severity of truncal acne vulgaris. Approximately 50% of patients who presented with acne vulgaris demonstrated involvement on the chest and/or back, with more than 3% presenting with truncal acne lesions alone. Interestingly, approximately 1 out of 4 patients who presented with both facial and truncal acne involvement did not voluntarily mention the presence of truncal acne as part of their presenting complaint. In such cases, the presence of truncal acne lesions was detected by clinical examination. A grading system for truncal acne vulgaris is also presented. The majority of patients presenting with truncal acne vulgaris exhibited mild to moderate severity and more than 75% were interested in treatment for truncal acne lesions.

The position not the presence of the halogen in corticosteroids influences potency and side effects.

Many topical corticosteroids currently on the market contain a halogen substitution at the C6, C9, or the side-chain C21 position of the corticosteroid skeleton. These modifications have enhanced the efficacy of corticosteroids as compared to hydrocortisone as topical anti-inflammatory agents, but have often increased side effects such as skin atrophy, adrenal suppression, and telangiectasia. These side effects have been attributed to the presence of halogens in the corticosteroid molecule and have raised concerns regarding the safety of all halogenated corticosteroids. In this review, we assert that it is the position and nature of the halogen atom(s) in the corticosteroid molecule that determine potency/toxicity, rather than their mere presence. A greater understanding of the role of halogenation in determining corticosteroid potency and side effects will clarify why all halogenated steroids are not the same.

Multivesicular emulsion: a novel, controlled-release delivery system for topical dermatological agents.

Multivesicular emulsion systems are a new patented technology for topical delivery of pharmaceutical and over-the-counter actives. This novel technology involves the creation of a 2-phase, oil-in-water emulsion system that produces concentric multilamellar spheres of oil and water. Active ingredients can be released from their respective layers upon application to the skin. In addition to a controlled-release of active agents, the multivesicular emulsion base improves the biophysical properties of the skin by reducing transepidermal water loss and enhancing skin hydration. This technology has been applied to 6% salicylic acid formulations that in clinical experience show efficacy with high tolerance in several hyperkeratotic disorders. Subjects' self-assessment was clearly indicative of the excellent cosmetic elegance of the multivesicular emulsion system.

Combining clindamycin 1%-benzoyl peroxide 5% gel with multiple therapeutic options.

This article reports on recent studies and case reports that evaluated the stability, tolerability, and efficacy of clindamycin 1%-benzoyl peroxide 5% tube gel in combination with topical retinoids and oral antibiotics. Overall, these combinations appeared to be well-tolerated, effective, and, as reported in the case studies, adaptable to common clinical practice.

Lymphangioma circumscriptum: treatment with hypertonic saline sclerotherapy.

A 38-year-old woman came for treatment of multiple clear vesicles and hemorrhagic papules on the posterior aspect of the right shoulder and the right axillary vault of 5 years' duration. These lesions would spontaneously manifest as clear or blood-filled vesicles (or both) and appear to be exacerbated by physical contact from certain articles of clothing. A biopsy was done and the results revealed lymphangioma circumscriptum. The purpose of this case study was to evaluate a new form of treatment of lymphangioma circumscriptum with the use of 23.4% hypertonic saline sclerotherapy. The patient's lymphangioma circumscriptum significantly resolved with minimal side effects, such as mild hyperpigmentation. Decreased sensitivity was noted and no further treatment was indicated. This case showed that hypertonic saline 23.4% solution can be effective in treating the appearance of vesicles containing clear fluid or lymph and those containing red blood cells in superficial lymphangiomas and that this treatment can be considered for long-term management of lymphangioma circumscriptum.

Topical metronidazole combination therapy in the clinical management of rosacea.

Metronidazole was the first topical agent approved by the U.S. Food and Drug Administration for the treatment of rosacea. Several controlled studies have confirmed the efficacy and safety of topical metronidazole 0.75% gel, lotion and cream and 1% cream for rosacea. At present, little data exists regarding the use of combination topical therapy in rosacea management, although anecdotal evidence and preliminary studies suggest at least some additive benefit when topical metronidazole is used in combination with sulfacetamide 10% /sulfur 5%. In this paper, the results of observational experience evaluating topical metronidazole 0.75% gel used in combination with other topical rosacea therapies and/or subantimicrobial dose doxycycline are reported.

The pharmacologic therapy of rosacea: a paradigm shift in progress.

A number of topical and systemic pharmacologic therapies, some of which remain investigational, have been used to treat rosacea. The pathophysiology of rosacea appears to be inflammatory, and most of the interventions modulate the inflammatory process in some way. Topical agents include various formulations of sodium sulfacetamide and sulfur, metronidazole, azelaic acid, and benzoyl peroxide/clindamycin. Oral agents include antibiotics in conventional and subantimicrobial doses. A paradigm shift in progress in the management of rosacea encompasses the use of these and other agents either alone or, increasingly, in different combinations, based on the subtype of rosacea.

Clinical experience results with clindamycin 1% benzoyl peroxide 5% gel (Duac) as monotherapy and in combination.

This article will examine various clinical experiences with acne patients successfully treated with topical clindamycin 1% benzoyl peroxide 5% gel (Duac) alone and in combination with other acne treatments. Clindamycin 1% benzoyl peroxide 5%, the only once-daily prescription topical aqueous gel combining a benzoyl peroxide and an antibiotic, has demonstrated excellent tolerability and efficacy and is stable when used concomitantly with other therapies. A regimen of topical clindamycin 1% benzoyl peroxide 5% gel, oral doxycycline hyclate (Doryx), and adapalene gel (Differin) seems especially advantageous from a theoretical and practical perspective. Improvement is noted by means of photographic, physician, and/or patient assessments at baseline and follow-up visits.