Systemic treatments for atopic dermatitis (eczema): Systematic review and network meta-analysis of randomized trials.

BACKGROUND: Atopic dermatitis (AD) is an inflammatory skin condition with multiple systemic treatments and uncertainty regarding their comparative impact on AD outcomes. OBJECTIVE: We sought to systematically synthesize the benefits and harms of AD systemic treatments. METHODS: For the 2023 American Academy of Allergy, Asthma & Immunology and American College of Allergy, Asthma, and Immunology Joint Task Force on Practice Parameters AD guidelines, we searched MEDLINE, EMBASE, CENTRAL, Web of Science, and GREAT databases from inception to November 29, 2022, for randomized trials addressing systemic treatments and phototherapy for AD. Paired reviewers independently screened records, extracted data, and assessed risk of bias. Random-effects network meta-analyses addressed AD severity, itch, sleep, AD-related quality of life, flares, and harms. The Grading of Recommendations Assessment, Development and Evaluation approach informed certainty of evidence ratings. This review is registered in the Open Science Framework (https://osf.io/e5sna). RESULTS: The 149 included trials (28,686 patients with moderate-to-severe AD) evaluated 75 interventions. With high-certainty evidence, high-dose upadacitinib was among the most effective for 5 of 6 patient-important outcomes; high-dose abrocitinib and low-dose upadacitinib were among the most effective for 2 outcomes. These Janus kinase inhibitors were among the most harmful in increasing adverse events. With high-certainty evidence, dupilumab, lebrikizumab, and tralokinumab were of intermediate effectiveness and among the safest, modestly increasing conjunctivitis. Low-dose baricitinib was among the least effective. Efficacy and safety of azathioprine, oral corticosteroids, cyclosporine, methotrexate, mycophenolate, phototherapy, and many novel agents are less certain. CONCLUSIONS: Among individuals with moderate-to-severe AD, high-certainty evidence demonstrates that high-dose upadacitinib is among the most effective in addressing multiple patient-important outcomes, but also is among the most harmful. High-dose abrocitinib and low-dose upadacitinib are effective, but also among the most harmful. Dupilumab, lebrikizumab, and tralokinumab are of intermediate effectiveness and have favorable safety.

Complementary and Alternative Therapies for Onychomycosis: A Systematic Review of the Clinical Evidence.

Introduction: Onychomycosis is notoriously difficult to treat. While oral antifungals are the most efficacious treatment for onychomycosis, they are contraindicated in certain patient populations, and patients may desire lower risk and accessible alternatives to systemic agents. In this study, we examine the clinical evidence supporting the use of complementary and alternative therapies in the treatment of onychomycosis. Methods: PubMed, Embase, and Cochrane Library were searched for clinical trials, observational studies, and case reports/case series, examining the efficacy of a complementary or alternative therapy for the treatment of onychomycosis. Results: We identified 17 articles studying a complementary and alternative therapy for onychomycosis, including tea tree oil (n = 5), Ageratina pichinchensis (n = 3), Arthrospira maxima (n = 2), natural coniferous resin lacquer (n = 2), Vicks VapoRub® (n = 2), propolis extract (n = 2), and ozonized sunflower oil (n = 1). Conclusion: Given the rise of antifungal resistance, complementary and alternative therapies should continue to be studied as adjunctive or alternative therapy for onychomycosis. While preliminary evidence exists for several complementary and alternative therapies in the treatment of onychomycosis, large-scale, randomized, placebo-controlled trials are needed prior to endorsing their use to patients.

The Role of Diet Modification in Atopic Dermatitis: Navigating the Complexity.

Diet has long been understood to have an intricate association with atopic dermatitis, although much remains unelucidated. Skin barrier dysfunction with dysbiosis and consequent impairment of immune tolerance likely underly the pathogenesis of coincident atopic dermatitis and food allergy. There is a wide range of possible skin reactions to food, complicating the diagnosis and understanding of food allergies. Many patients, parents, and providers incorrectly suspect diet as causative of atopic dermatitis symptoms and many have tried elimination diets. This frequently leads to inaccurate labeling of food allergies, contributing to a dangerous spiral of inappropriate testing, referrals, and dietary changes, while neglecting established atopic dermatitis treatment essentials. Alternatively, certain dietary supplements or the introduction of certain foods may be beneficial for atopic dermatitis management or prevention. Greater consensus on the role of diet among providers of patients with atopic dermatitis is strongly encouraged to improve the management of atopic dermatitis.

Myths and media in oral collagen supplementation for the skin, nails, and hair: A review.

BACKGROUND: As a key component of the hair, skin, and nails, there is strong consumer interest in the dermatologic efficacy of oral collagen supplementation. Oral supplementation with collagen peptides has increased in popularity in recent years. AIMS: There are relatively few studies investigating the dermatologic effects of ingested collagen peptides, many of which are limited by sample size and variability of results. The question remains whether there is sufficient evidence to support companies' promises and consumers' goals. METHODS: In this review, we investigate and compare the claims surrounding collagen supplementation on Instagram and YouTube, made by collagen companies, and established in the literature. RESULTS: Although some studies have demonstrated that collagen supplementation can enhance skin qualities such as elasticity and hydration, dermatologic claims in the media surpass any evidence currently supported by the literature. CONCLUSIONS: More research is needed to establish knowledge of the effects and physiologic mechanism of collagen supplementation. Dermatologists should be aware of the unsubstantiated proclamations of collagen made by companies and in social media, as well as what evidence is established thus far, to be equipped to discuss collagen supplementation with patients.

Acupuncture in Dermatology: An Update to a Systematic Review.

Objectives: Acupuncture is an important Traditional Chinese Medicine modality based on the fundamental theory that disease is caused by disruptions in the body's qi. Understanding the use of acupuncture in dermatology is important due to the rising prevalence of complementary and alternative medicine use. A systematic review published in 2015 found that acupuncture improves outcomes in several dermatological diseases. We performed a systematic review of studies that have been done since then to present updated evidence. Methods: A systematic search of MEDLINE, EMBASE, and the Cochrane Central Register was performed. Studies were limited to clinical trials, controlled studies, case reports, comparative studies, and systematic reviews published in the English language. Studies involving moxibustion, electroacupuncture, or blood-letting were excluded. Results: Results showed that acupuncture improves clinical outcomes in uremic pruritus, atopic dermatitis, urticaria, and itch. Acupuncture does not significantly reduce postoperative itch in patients undergoing cesarean section under spinal anesthesia. Conclusions: While there are some promising studies that support the use of acupuncture for skin diseases, additional large-scale, randomized, sham-controlled trials need to be performed to present consistent high-level evidence of acupuncture's role in dermatology.

Atopic Dermatitis and the Role of the Skin Microbiome in Choosing Prevention, Treatment, and Maintenance Options.

BACKGROUND: Atopic dermatitis (AD) is a common skin condition characterized by disturbed barrier function, skin inflammation, and cutaneous dysbiosis. Clinically, it manifests as chronic-recurrent xerosis, pruritus, and erythematous lesions. Its pathophysiology is complex, making the selection of appropriate treatment options a task. AIM: To share insights gained from a literature review and discussions with experts in dermatology on key factors related to the prevention, treatment, and management of AD in relation to the skin microbiome. METHODS: Results from an expert panel were summarized and discussed to provide updated recommendations for the treatment and maintenance of AD. RESULTS: Evidence supports a strategy for managing inflammatory skin diseases with a selenium-rich post-biotic thermal water and biomass containing moisturizer. The moisturizer helps to restore homeostasis of the skin, re-populate a diverse microbiome, encourage the growth of commensal bacteria, and improve barrier function and symptoms of AD. CONCLUSIONS: Normalization of skin microbiome diversity using a topical moisturizer containing post-biotic aqua and biomass may offer a valuable option for the treatment and maintenance of inflammatory skin diseases. Clinicians should discuss the benefits of this treatment in the context of a full AD management program that covers prevention, active treatment, and maintenance. J Drugs Dermatol. 2020;19(10):935-940. doi:10.36849/JDD.2020.5393.

Alternative Treatments for Atopic Dermatitis: An Update.

Atopic dermatitis (AD) is a chronic pruritic inflammatory skin disease in which management with topical anti-inflammatory agents during exacerbations remains the mainstay of treatment. With no cure in sight, a significant proportion of patients elect to incorporate complementary and alternative medicine (CAM) as an adjunct to conventional treatment. Many clinicians find it difficult to provide recommendations as the field covers an extensive number of very disparate therapies, with limited quality evidence to indicate efficacy. Since publication of the last review on this topic in the Journal that compiled and analyzed randomized controlled trials (RCTs) on CAMs in 2015, several new studies have surfaced. This update aims to aggregate and review these new data. A literature search was conducted in the PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and Global Resource for EczemA Trials (GREAT) databases for RCTs on complementary and alternative therapies in AD from March 2015 through May 2018, resulting in 15 studies being included in this review. The preliminary results for many treatments such as vitamin E, East Indian Sandalwood Oil (EISO), melatonin, L-histidine, and Manuka honey show positive clinical effects, but there is currently not enough evidence to recommend their use in AD therapy. Future investigative efforts should focus on reproducing some of these studies with a larger sample size whose clinical characteristics and demographics are more reflective of the general AD population, and standardizing the process to produce reliable data.

The Role of Elimination Diets in Atopic Dermatitis-A Comprehensive Review.

BACKGROUND/OBJECTIVES: Diet is a common concern for individuals with atopic dermatitis (AD) and their families. Studies regarding the effect of dietary interventions on AD exist, but many are limited by small size and poor design. Conflicting results present a challenge to clinicians seeking to counsel patients. The aim of the current review is to examine the published literature and generate helpful conclusions for clinicians faced with dietary questions in AD. METHODS: A PubMed search was performed focusing on dietary interventions for AD in children and adults through July 2016. The search was limited to the English language and included studies that evaluated one or more forms of dietary modification for the treatment of AD. Studies of supplementation, such as with vitamins, minerals, or probiotics, were not included, nor were studies on prevention of the development of AD. A total of 43 articles met the inclusion criteria and were included in the final analysis. RESULTS: Trials varied in type, duration, and the AD patient populations studied. Overall, there is some level I evidence to support specific exclusion diets in preselected patients but insufficient evidence for strict elimination diets (diets that are typically limited to six to eight foods). Data supporting other interventions are mixed and based on small, poorly designed studies. CONCLUSIONS: A comprehensive literature review reveals some promising results and several areas in need of further study. More evidence is needed to form a strong foundation for recommendations regarding the utility and role of elimination diets in AD management, but current evidence suggests that strict diet management is not effective in the treatment AD in the vast majority of patients.

The Role of Polyphenols in Rosacea Treatment: A Systematic Review.

OBJECTIVES: Various treatment options are available for the management of rosacea symptoms such as facial erythema, telangiectasia, papules and pustules, burning, stinging, and itching. Botanical therapies are commonly used to treat the symptoms. The objective of this review is to evaluate the use of polyphenols in rosacea treatment. DESIGN: PubMed, Embase, Biosis, Web of Knowledge, and Scopus databases were systematically searched for clinical studies evaluating polyphenols in the management of rosacea. RESULTS: Of 814 citations, 6 met the inclusion criteria. The studies evaluated licochalcone (n = 2), silymarin (n = 2), Crysanthellum indicum extract (n = 1), and quassia extract (n = 1). The studies only evaluated topical formations of stated polyphenols. Main results were summarized. CONCLUSIONS: There is evidence that polyphenols may be beneficial for the treatment of rosacea symptoms. Polyphenols appear to be most effective at reducing facial erythema and papule and pustule counts. However, studies included have significant methodological limitations and therefore large-scale, randomized, placebo-controlled trials are warranted to further assess the efficacy and safety of polyphenols in the treatment of rosacea.

Case Series Study of the Efficacy of Compounded Antibacterial, Steroid, and Moisturizer in Atopic Dermatitis.

BACKGROUND/OBJECTIVES: Previous studies have demonstrated that the use of a topical antimicrobial combined with a steroid may benefit patients with atopic dermatitis (AD), but modern guidelines discourage the use of antimicrobials in treating this condition. We sought to evaluate the degree of improvement in the severity and extent of AD lesions after using a compounded antibacterial, steroid, and moisturizer (CASM). METHODS: This was a nonblinded retrospective review of patients with AD treated using CASM. Multiple patients in the study had previously failed mid- or higher-potency topical steroids, systemic immunosuppressives, or phototherapy (standard therapy [ST] group). Patients were assessed at baseline and at one follow-up visit, with an average follow-up period of 49.5 days. We included all patients with AD in the database who were prescribed CASM and had one subsequent follow-up appointment. We excluded patients who had newly started a systemic immunosuppressant or phototherapy at the time of beginning CASM. RESULTS: We included 116 patients in the study. We observed a decrease in mean severity of 1.4 points on a 6-point scale and an average decrease in body surface area (BSA) affected of 23.2 ± 2.5% overall and a decrease in mean severity of 1.4 points and average decrease in BSA affected of 19.7 ± 2.8% in the ST group. CONCLUSION: CASM appears to be effective in the management of AD and may offer additional benefit for patients who have plateaued with standard therapies.

Complementary and Alternative Medicine for Atopic Dermatitis: An Evidence-Based Review.

BACKGROUND: Complementary and alternative interventions are becoming increasingly utilized as adjuncts to conventional treatment of atopic dermatitis (AD). While the number of studies continues to grow, the vastness of the subject coupled with the relatively poor quality and small size of the studies limit their usefulness to clinicians. PURPOSE: Our aim was to comprehensively review randomized controlled trials (RCTs) of complementary and alternative therapies for AD. METHODS: Searches were performed on PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, and the Global Resource for EczemA Trial (GREAT) databases, focusing on RCTs of alternative or complementary AD therapies, with a sample size of ≥10, through March 2015 and limited to the English language. A total of 70 manuscripts met the inclusion criteria and were included in the final analysis. RESULTS: There is at least some level I evidence to support the use of acupuncture and acupressure, stress-reducing techniques such as hypnosis, massage, and biofeedback, balneotherapy, herbal preparations (with many important caveats), certain botanical oils, oral evening primrose oil, vitamin D supplementation, and topical vitamin B12. Many other therapies either have sufficient data to suggest that they are ineffective, or simply do not have enough evidence to formulate a verdict. CONCLUSIONS: Careful review of the literature reveals several promising therapies in this domain; such findings may help direct further research that is necessary to bolster clinical recommendations for alternative or complementary treatments of AD.

Alternative, Complementary, and Forgotten Remedies for Atopic Dermatitis.

Atopic dermatitis, perhaps more than other dermatologic diseases, has garnered much attention in the realm of alternative medicine. This may be because its etiopathogenesis is incompletely understood, it is increasingly common, and it waxes and wanes often without clear precipitants, opening up many opportunities for misinterpretation. Herein we explore the evidence for a number of different alternative and complementary therapies, from textiles to vitamin supplements. By definition, none have enough data to be deemed "effective" in a conventional sense, but it is hopeful that some show promising evidence that may one day lead to mainstream acceptance with further research.

Non-pharmacologic therapies for atopic dermatitis.

Atopic dermatitis (AD) continues to present significant therapeutic challenges, especially in severe cases. Navigating the line between risk and benefit can be difficult for more powerful medications such as immunosuppressants, but non-pharmacologic treatments are often overlooked and underutilized. Creative application of these more physical therapies can serve to minimize the pharmacologic treatments and their side effects, and possibly even create synergy between modalities, to maximize benefit to the patient.

Effectiveness of acupressure on pruritus and lichenification associated with atopic dermatitis: a pilot trial.

BACKGROUND: Pruritus is a debilitating aspect of atopic dermatitis (AD). Acupuncture has been reported to diminish pruritus, but self-administered acupressure has not been previously evaluated. OBJECTIVES: To evaluate the effectiveness of acupressure on the severity of eczema in a pilot trial. METHODS: Adult patients with AD were randomised to an intervention group (acupressure with standard of care) or a control group (standard of care alone). Subjects in the intervention group performed acupressure using a 1.2 mm acupellet at the LI11 point, applying pressure for 3 min three times per week for 4 weeks. The severity of itching and AD at baseline and at 4 weeks were measured on a visual analogue scale (VAS), the Investigator's Global Assessment (IGA) and the Eczema Area and Severity Index (EASI). RESULTS: Fifteen subjects were enrolled, 12 of whom completed the study between November 2009 and May 2011. There was no significant change between baseline and follow-up survey scores within the control group. In the investigation group there was a decrease in the VAS score (p=0.05) and EASI lichenification (p=0.03), although without significant change in the overall EASI score. Comparison of the scores between groups showed a greater decrease in VAS in the experimental group than in the control group (p=0.04), and a decrease in the IGA (p=0.03) and EASI lichenification score (p=0.03). The overall EASI scores were unchanged. CONCLUSION: Subjects using acupressure at LI11 for 4 weeks had improvement in pruritus and lichenification. Acupressure may prove to be an easily administered alternative treatment, but larger-scale studies are needed to confirm these preliminary findings.

Double trouble: therapeutic challenges in patients with both juvenile dermatomyositis and psoriasis.

BACKGROUND: Juvenile dermatomyositis (JDM) and psoriasis are inflammatory disorders that share interferon-α induced responses and dysregulation of cytokines, including tumor necrosis factor alpha. Although 13% of patients with JDM have a family history of psoriasis there is little information concerning children with JDM and psoriasis. OBSERVATIONS: We identified 3 children with both JDM and psoriasis. In 2 cases, psoriatic lesions occurred after the child's JDM symptoms had diminished following effective immunosuppressive therapy (high-dose intermittent intravenous methylprednisolone, methotrexate, and low dose oral corticosteroids). Patient 2, initially diagnosed as having psoriasis, was treated with prednisone and methotrexate but then developed classic JDM, which worsened following use of tumor necrosis factor alpha inhibitor and reduction of prednisone and methotrexate dosage. For each child, their history of JDM complicated the choice of therapy for psoriasis. CONCLUSIONS: Two therapies commonly used to treat psoriasis-phototherapy and tumor necrosis factor-alpha antagonists-must be used with caution in patients with both JDM and psoriasis owing to their potential to exacerbate clinical manifestations of JDM. We discuss the implications affecting treatment of children with these dual diagnoses and consider the pathophysiology linking these 2 conditions.

Adverse effects of a mole removal cream.

Mole removal creams available over the Internet pose potential dangers to unsuspecting patients. We report a case of keloid development following the application of such a product.