Treatment of clinically amyopathic dermatomyositis in adults: a systematic review.

Clinically amyopathic dermatomyositis (CADM) affects a subset of 5-20% of patients with dermatomyositis and is defined as the presence of cutaneous features of dermatomyositis without clinical muscle weakness for ≥ 6 months. There is no consensus on first-line treatment for CADM and whether treatment should differ from treatment of classic dermatomyositis with muscle weakness. We carried out a systematic review of published literature about treatment of adult patients with CADM, via the Embase, Medline, CINAHL and ClinicalTrials.gov databases on 17 February 2015. The aim was to establish which treatments have been used for adult-onset CADM and what evidence is available regarding the efficacy of these treatments including topical treatments, dapsone, antimalarials, intravenous immunoglobulin (IVIG), nonsteroidal oral immunosuppressants and biological therapies. Eighteen cases series and 42 case reports were found. These provided data on 153 adult patients who met the inclusion criteria. No randomized controlled trials or robust observational studies were found. The majority of patients (60%) had tried more than one treatment due to side-effects or lack of efficacy. Antimalarial agents were the most commonly used treatment type. In the majority of patients (55%), antimalarial treatments were discontinued due to lack of improvement or inability to wean concomitant steroids. IVIG was the treatment that led to improvement or remission in the greatest proportion of patients. Further robust, high-quality studies are needed to assess treatment efficacy in CADM without bias.

How to write a Critically Appraised Topic: evidence to underpin routine clinical practice.

Critically appraised topics (CATs) are essential tools for busy clinicians who wish to ensure that their daily clinical practice is underpinned by evidence-based medicine. CATs are short summaries of the most up-to-date, high-quality available evidence that is found using thorough structured methods. They can be used to answer specific, patient-orientated questions that arise recurrently in real-life practice. This article provides readers with a detailed guide to performing their own CATs. It is split into four main sections reflecting the four main steps involved in performing a CAT: formulation of a focused question, a search for the most relevant and highest-quality evidence, critical appraisal of the evidence and application of the results back to the patient scenario. As well as helping to improve patient care on an individual basis by answering specific clinical questions that arise, CATs can help spread and share knowledge with colleagues on an international level through publication in the evidence-based dermatology section of the British Journal of Dermatology.

Dipping and jetting with tea tree (Melaleuca alternifolia) oil formulations control lice (Bovicola ovis) on sheep.

The in vivo pediculicidal effectiveness of 1% and 2% formulations of tea tree (Melaleuca alternifolia) oil (TTO) against sheep chewing lice (Bovicola ovis) was tested in two pen studies. Immersion dipping of sheep shorn two weeks before treatment in both 1% and 2% formulations reduced lice to non detectable levels. No lice were found on any of the treated sheep despite careful inspection of at least 40 fleece partings per animal at 2, 6, 12 and 20 weeks after treatment. In the untreated sheep louse numbers increased from a mean (± SE) of 2.4 (± 0.7) per 10 cm fleece part at 2 weeks to 12.3 (± 4.2) per part at 20 weeks. Treatment of sheep with 6 months wool by jetting (high pressure spraying into the fleece) reduced louse numbers by 94% in comparison to controls at two weeks after treatment with both 1% and 2% TTO formulations. At 6 and 12 weeks after treatment reductions were 94% and 91% respectively with the 1% formulation and 78% and 84% respectively with the 2% formulation. TTO treatment also appeared to reduce wool damage in infested sheep. Laboratory studies indicated that tea tree oil 'stripped' from solution with a progressive reduction in concentration as well as volume as more wool was dipped, indicating that reinforcement of active ingredient would be required to maintain effectiveness when large numbers of sheep are treated. The results of these studies suggest significant potential for the development of ovine lousicides incorporating TTO.

Bioactivity of tea tree oil from Melaleuca alternifolia against sheep lice (Bovicola ovis Schrank) in vitro.

Tea tree oil (TTO) from the Australian native plant Melaleuca alternifolia has wide ranging bio-active properties, including insecticidal and repellent activity against arthropods. Furthermore, composition of commercially available Australian TTO is specified under an International Organization for Standardization standard (ISO 4730), reducing the potential for variable effects often noted with botanical pesticides. The effect of TTO, meeting the ISO standard for terpinen-4-ol chemotype, was tested against sheep lice (Bovicola ovis Schrank) in a series of laboratory studies. Immersion of wool for 60s in formulations containing concentrations of 1% TTO and above caused 100% mortality of adult lice and eggs. Exposure to vapours from TTO, delivered as droplets in fumigation chambers and when applied to wool also caused high mortality in both lice and eggs. The main active component of TTO in the fumigant tests was terpinen-4-ol. Treated surface assays and tests with wool where the formulation was allowed to dry before exposure of lice indicated low persistence. These studies demonstrate that TTO is highly toxic to sheep lice and active at concentrations that suggest potential for the development of TTO-based ovine lousicides.

Insecticidal and repellent effects of tea tree (Melaleuca alternifolia) oil against Lucilia cuprina.

Laboratory studies were conducted to assess the effect of tea tree oil (TTO) from Melaleuca alternifolia (terpinen-4-ol chemotype) against different stages of the Australian sheep blowfly Lucilia cuprina. When applied to wool, 3% TTO formulation repelled gravid female L. cuprina and prevented oviposition for six weeks. Formulations containing 1% TTO caused 100% mortality of L. cuprina eggs and 1st instar larvae and 2.5% TTO caused mortality of most second and third instar larvae in agar feeding assays. In experiments where third instar larvae were dipped in TTO formulations for 60s, concentrations of up to 50% TTO gave less than 50% kill. TTO at concentrations of 0.5%, 2% and 5% was strongly repellent to third instar larvae and caused them to evacuate treated areas. Inclusion of TTO in formulations with diazinon, ivermectin and boric acid reduced mortality in comparison with the larvicides used alone, at least partially because of avoidance behaviour stimulated by the TTO. Addition of TTO to wound treatments may aid in wound protection and myiasis resolution by preventing oviposition by L. cuprina adults, insecticidal action against L. cuprina eggs and larvae, stimulating larvae to leave the wound and through antimicrobial and anti-inflammatory properties that aid in wound healing.