Dairy and nondairy beverage consumption for childhood atopic eczema: what health advice to give?

BACKGROUND: Many parents of children with atopic eczema (AE) practise empirical dietary avoidance and supplementation, and seek healthcare advice on whether consumption of dairy and nondairy beverages may be beneficial or detrimental for this condition. AIM: We investigated if frequency of consumption of beverages was associated with disease severity and quality of life (QoL). METHODS: Parent-reported frequency of drinks and beverages were recorded in consecutive children with AE, and disease severity (Nottingham Eczema Severity Score; NESS), QoL (Children's Dermatology Life Quality Index; CDLQI), skin hydration (SH), transepidermal water loss (TEWL), blood pressure (BP), resting heart rate (RHR) and body mass index (BMI) were evaluated. RESULTS: AE was associated with worse QoL than miscellaneous non-AE skin diseases (P < 0.001). Compared with children without AE, there was a trend for children with AE to drink less milk (P = 0.06) and more miscellaneous beverages (such as Chinese herbal tea and soymilk; P = 0.03). In children with AE, NESS correlated with CDLQI (ρ = 0.66, P < 0.001) and reduced SH (ρ = -0.32, P < 0.001), whereas CDLQI correlated with a higher RHR (ρ = 0.25, P < 0.01). Multiple logistic regression showed that male sex (OR = 0.44, 95% CI 0.20-0.97; P = 0.04) and drinking fresh milk (OR = 0.42, 95% CI 0.20-0.93; P = 0.03) were independent factors associated with less severe disease. Moderate to severe impairment of CDLQI was associated with NESS (OR = 1.48, 95% CI 1.28-1.71; P < 0.001) and RHR (OR = 1.05, 95% CI 1.02-1.08; P < 0.01) but not with reported habits of beverage consumption. Concerning cardiovascular health in AE, frequency of formula milk consumption was associated with RHR (ρ = 0.17, P = 0.04), and soft drink consumption was associated with higher systolic blood pressure (SBP) (ρ = 0.18, P = 0.04). CONCLUSION: This study provides evidence for parental/patient guidance. Children with AE who reported more fresh milk consumption had less severe disease. There was no correlation between consumption of nondairy beverages with disease severity or QoL, but frequency of soft drink consumption correlated with SBP. With these results being supported by a literature review, it is reasonable to advise parents that fresh milk can be consumed by unsensitized children with AE. Soft drinks and other beverages should not be consumed in excess for optimal cardiovascular health and for other health reasons.

Patient acceptability, efficacy, and skin biophysiology of a cream and cleanser containing lipid complex with shea butter extract versus a ceramide product for eczema.

OBJECTIVES: To investigate patient acceptability, efficacy, and skin biophysiological effects of a cream/cleanser combination for childhood atopic dermatitis. SETTING: Paediatric dermatology clinic at a university teaching hospital in Hong Kong. PATIENTS: Consecutive paediatric patients with atopic dermatitis who were interested in trying a new moisturiser were recruited between 1 April 2013 and 31 March 2014. Swabs and cultures from the right antecubital fossa and the worst eczematous area, disease severity (SCORing Atopic Dermatitis index), skin hydration, and transepidermal water loss were obtained prior to and following 4-week usage of a cream/cleanser containing lipid complex with shea butter extract (Ezerra cream; Hoe Pharma, Petaling Jaya, Malaysia). Global or general acceptability of treatment was documented as 'very good', 'good', 'fair', or 'poor'. RESULTS: A total of 34 patients with atopic dermatitis were recruited; 74% reported 'very good' or 'good', whereas 26% reported 'fair' or 'poor' general acceptability of treatment of the Ezerra cream; and 76% reported 'very good' or 'good', whereas 24% reported 'fair' or 'poor' general acceptability of treatment of the Ezerra cleanser. There were no intergroup differences in pre-usage clinical parameters of age, objective SCORing Atopic Dermatitis index, pruritus, sleep loss, skin hydration, transepidermal water loss, topical corticosteroid usage, oral antihistamine usage, or general acceptability of treatment of the prior emollient. Following use of the Ezerra cream, mean pruritus score decreased from 6.7 to 6.0 (P=0.036) and mean Children's Dermatology Life Quality Index improved from 10.0 to 8.0 (P=0.021) in the 'very good'/'good' group. There were no statistically significant differences in the acceptability of wash (P=0.526) and emollients (P=0.537) with pre-trial products. When compared with the data of another ceramide-precursor moisturiser in a previous study, there was no statistical difference in efficacy and acceptability between the two products. CONCLUSIONS: The trial cream was acceptable in three quarters of patients with atopic dermatitis. Patients who accepted the cream had less pruritus and improved quality of life than the non-accepting patients following its usage. The cream containing shea butter extract did not differ in acceptability or efficacy from a ceramide-precursor product. Patient acceptability is an important factor for treatment efficacy. There is a general lack of published clinical trials to document the efficacy and skin biophysiological effects of many of the proprietary moisturisers.

Antibiotic-resistant Propionibacterium acnes among acne patients in a regional skin centre in Hong Kong.

BACKGROUND: There has been no study on antibiotic-resistant Propionibacterium acnes in Hong Kong. OBJECTIVE: We investigated the prevalence and pattern of antibiotic-resistant P. acnes and to identify any associated factors for harbouring the resistant strains. METHODS: Culture and sensitivity testing of P. acnes to commonly used antibiotics were performed. Resistance to tetracycline was defined at a minimal inhibitory concentration (MIC) of 2 µg/mL or more; erythromycin at an MIC of 0.5 µg/mL or more; clindamycin at an MIC of 0.25 µg/mL or more according to EUCAST. For breakpoints of doxycycline and minocycline, those with an MIC of 1 µg/mL or more were defined as resistant strains. RESULTS: Among the 111 specimens collected from 111 patients, 86 strains of P. acnes were recovered, one from each specimen. Twenty-five specimens had no growth. Forty-seven (54.8%) strains were found to be resistant to one or more antibiotics. Forty-six (53.5%), 18 (20.9%), 14 (16.3%), 14(16.3%) and 14 (16.3%) strains were resistant to clindamycin (CL), erythromycin (EM), tetracycline (TET), doxycycline (DOX) and minocycline (MR) respectively. Ten strains (11.6%) had cross resistance between the MLS antibiotics (erythromycin or clindamycin), one strain (1.2%) had cross resistance among the cyclines and 14 strains (16.4%) had cross resistance between the MLS and cycline antibiotics. Binary logistic regression showed an association between MLS antibiotic resistance with an increased age whereas cycline resistance was associated with the duration of treatment. CONCLUSION: Antibiotic-resistant P. acnes is prevalent in Hong Kong. Dermatologists should be more vigilant in prescribing antibiotics for acne patients.

Efficacy and safety of diphenylcyclopropenone among Chinese patients with steroid resistant and extensive alopecia areata.

BACKGROUND: Topical immunotherapy has recently been found useful in the treatment of chronic and extensive Alopecia Areata (AA). OBJECTIVE: To evaluate the efficacy and safety of diphenylcyclopropenone (DPCP) use among Chinese patients with steroid resistant and extensive AA in our institute. METHODS: The medical records of 31 Chinese patients treated with DPCP were analysed retrospectively. The efficacy, adverse effects, and relapse rate of DPCP treatment were reviewed. RESULTS: Thirty-one (16 male, 15 female) Chinese patients with extensive, steroid resistant Alopecia Areata and a mean age of 28.9 years (SE 10.4) were treated. The mean age of onset was 17.8 years (SE 8.8) with an average disease duration of 11.2 years (SE 7.7). Ten patients had a history of atopy and 4 had a history of thyroid disease. Nail changes were found in 14 patients and a family history of AA was found in 2 patients. Thirteen patients (41.9%) had experienced total hair loss. Two patients abandoned the treatment due to severe side effects. Of the remaining 29 patients, 4 (13.8%), 7 (24.1%), 5 (17.2%), and 13 (44.8%) achieved >90% complete response, >50-90% partial response, >10-50% minimal response, and <10% no response hair regrowth, respectively. Adverse effects included pruritus, erythema, vesiculation, scaling, cervical lymphadenopathy, dyspigmentation and urticarial reactions. Relapse occurred (>25% hair loss) in 69.23% of patients after 18 months of follow up. CONCLUSIONS: DPCP is an effective and tolerable treatment for Chinese patients with extensive, steroid resistant AA.

Evaluation of PCR for the diagnosis of dermatophytes in nail specimens from patients with suspected onychomycosis.

BACKGROUND: Conventional methods for detecting fungi in nail specimens are either nonspecific (microscopy) or insensitive (culture). Recently, PCR has been used to improve sensitivity in detecting the causative fungi in nail specimens from patients with suspected onychomycosis. AIM: To compare the detection rates of PCR with those of microscopy (with potassium hydroxide; KOH) and culture for dermatophytes in nail specimens from patients with suspected onychomycosis. METHODS: In total, 120 patients with clinically suspected onychomycosis were recruited, and using a topoisomerase II-based PCR, we compared the detection rate of dermatophytes for the three methods. RESULTS: KOH microscopy, culture and PCR respectively yielded positive rates of 35 (29.2%), 12 (10%) and 48 (40%), and negative rates of 85 (70.8%), 108 (90%) and 72 (60%). Two culture-positive specimens were not detected by PCR, but PCR picked up 38 specimens missed by culture. Of the 35 specimens that were microscopy-positive, 12 grew dermatophytes and 23 nondermatophytes. CONCLUSIONS: This study demonstrates that PCR has a higher positive and lower negative rate for detection of dermatophytes compared with KOH microscopy or culture. We suggest that PCR should be used as a complementary method for confirmation of clinically suspected dermatophytic onychomycosis.

Pseudoceramide for childhood eczema: does it work?

OBJECTIVES: Atopic eczema is a chronic relapsing skin disease associated with atopy, and characterised by reduced skin hydration, impaired skin integrity (transepidermal water loss), and poor quality of life. Proper emollient usage is an important facet of its management. This study aimed to establish an approach to evaluate the efficacy of using an emollient over a 4-week period. DESIGN: Prospective observational study. SETTING: A paediatric dermatology out-patient clinic of a university teaching hospital in Hong Kong. PATIENTS: Consecutive new patients aged 5 to 18 years with atopic eczema diagnosed according to Hanifin and Rajka's criteria were recruited from March to August 2009. They or their parents were instructed to liberally apply the test emollient to the flexures and areas affected with eczema, twice daily. Outcome assessments were repeated 2 and 4 weeks later. MAIN OUTCOME MEASURES: Skin hydration and transepidermal water loss in the right forearm (2 cm below antecubital flexure), and disease severity (SCORing Atopic Dermatitis index) and Children's Dermatology Life Quality Index. At the end of the study period, a global assessment of treatment was recorded. RESULTS: Thirty-three patients with atopic eczema were recruited and treated with applications of a pseudoceramide-containing cream (Curel, Kao, Japan). The mean age of the patients (16 males and 17 females) was 12 (standard deviation, 4) years. Four weeks following the use of the cream, skin hydration improved significantly and fewer patients were using topical corticosteroids. In these patients, there was no deterioration in transepidermal water loss, eczema severity, or quality of life. CONCLUSION: The pseudoceramide cream improved skin hydration but not severity or quality of life over a 4-week usage.

Spontaneous regression of primary cutaneous Epstein-Barr virus-positive, CD30-positive anaplastic large T-cell lymphoma in a heart-transplant recipient.

We presented a rare case of primary cutaneous Epstein-Barr virus-positive, CD30-positive anasplastic large cell lymphoma in a 64-year-old man who had received a heart transplant 11 years previously. The first presenting symptom was the appearance of erythematous skin nodules on the right leg. The lesions subsided with dose reduction of immunosuppressant alone. There was no recurrence 9 months after the first diagnosis. We propose that dose reduction of immunosuppressant alone may be an effective treatment for localized, indolent, post-transplant-related primary cutaneous lymphoma. Our case shows the importance of regular surveillance of skin cancer in patients who have received organ transplant.

Topical 5-fluorouracil has no additional benefit in treating common warts with cryotherapy: a single-centre, double-blind, randomized, placebo-controlled trial.

The role of topical 5-fluorouracil (5-FU) in treating common warts is not well defined. We tried to evaluate the efficacy and adverse effects of combination cryotherapy and topical 5% 5-FU ointment in the treatment of common warts. The study was a single-centre, double-blind randomized placebo-controlled trial. In the study, 80 patients with common warts were randomized into two groups and underwent two 10-second freeze/thaw cycles of cryotherapy with liquid nitrogen once every three weeks for a maximum of five treatments. Between treatments, patients applied either topical 5% 5-FU ointment (group A) or placebo aqueous cream (group B) twice daily. The mean +/- SD reduction in wart area was 58.57 +/- 0.06% in group A and 65.29 +/- 0.06% in group B. In total, 19 patients in group A and 24 patients in group B had wart size reduced by 75% or more (P = 0.50), while 12 patients in group A and 17 patients in group B had clearance of their warts (P = 0.245). Logistic regression with age, sex, smoking status, immune status, site, duration and number of warty lesions, history of previous treatment, and treatment group found that only a history of previous treatment and acral lesions were significant adverse predictors of improvement. There was no significant difference in the number of adverse events between the two groups, although there was a trend towards more pain and blistering associated with topical 5-FU. We concluded that topical 5-FU has no added benefit in treating common warts with cryotherapy.

Clinicopathological features and prognostic factors of cutaneous melanoma among Hong Kong Chinese.

Cutaneous melanoma is rare among Chinese people. The clinicopathologic features and prognostic factors of 63 Hong Kong ethnic Chinese cases were analysed. We found that the mean age of onset was 65.5 years with a female : male ratio of 1 : 1.33. Forty-two (66.7%) patients had their tumours on their feet. More than 50% had the acral lentiginous histologic subtype. The mean tumour thickness was 5.73 mm with 92.1% (n = 58) having a Clark's level of III or more. Of the tumours, 57.1% were ulcerated. Stage I and II tumours comprised 73% (n = 46) while stage III and IV tumours made up of 26% (n = 17). The 1-, 3- and 5-year survival rates were 75%, 30% and 17%, respectively. Univariate analysis for overall survival showed that advanced clinical staging (stage III and IV), tumour ulceration and thicker tumour (>4 mm) had a significantly poorer prognosis. Multivariate analysis demonstrated that advanced clinical staging was the most decisive prognostic factor followed by tumour ulceration. Our study showed that cutaneous melanoma in Chinese people is a disease predominantly of an older age group with the acral lentiginous histologic type located mainly on the feet. The prognosis depends on clinical staging and ulceration status.

Skin metastasis from nasopharyngeal carcinoma in four Chinese patients.

Nasopharyngeal carcinoma (NPC) is a common malignancy among southern Chinese. The tumours are mostly undifferentiated carcinomas and are associated with Epstein-Barr virus. Patients present with a blood-stained postnasal discharge, impaired hearing, tinnitus or cervical lymph node enlargement. Radiotherapy with or without chemotherapy is the standard treatment. Though metastatic lung, bone or liver disease is not uncommon on relapse, skin metastasis is rarely reported. The small number of reports in the literature are either brief or have only a few patients. In this report, we describe our series of four Hong Kong Chinese patients with NPC who had distant cutaneous metastases.

Extramammary Paget's disease: outcome of radiotherapy with curative intent.

Six patients with extramammary Paget's disease were treated with curative intent radiotherapy. Two of the patients had associated underlying adenocarcinoma. Radiotherapy was given as primary treatment (two patients), definitive treatment for postexcisional relapse (three patients) and adjuvant treatment (one patient). Radiotherapy techniques included high dose rate mould brachytherapy, electron beam, superficial X-ray and photon treatments. Follow-up durations after radiotherapy were 1.2-14.8 years. Complete response was obtained in five patients while one patient had a partial response. Marginal failure occurred in one complete-responder who was successfully salvaged by surgery. The two patients with underlying adenocarcinoma died of distant metastasis. Radiotherapy side effects were acute confluent wet desquamation and mild late skin atrophy. Our results confirmed the useful role of radiotherapy in the management of extramammary Paget's disease.

Special features of non-melanoma skin cancer in Hong Kong Chinese patients: 10-year retrospective study.

OBJECTIVE: To determine the incidence and clinical characteristics of non-melanoma skin cancer in Hong Kong Chinese patients. DESIGN: Retrospective study. SETTING: Social Hygiene Services, Hong Kong. PATIENTS: Records of 528 Chinese patients with a histological diagnosis of non-melanoma skin cancer from 1990 to 1999 were reviewed. MAIN OUTCOME MEASURES: Demographic data, site and clinical type of cancer, predisposing factors, history, recurrence, and the development of new skin cancers. RESULTS: Non-melanoma skin cancer is uncommon but not rare among the Chinese population in Hong Kong. The incidence of newly diagnosed basal cell carcinoma in 1990 was 16.0 per 10,000 new skin case attendances and, in 1999, the incidence was 31.8 per 10,000 new skin case attendances. The corresponding figures for squamous cell carcinoma in 1990 and 1999 were 6.9 and 11.6 per 10,000 new skin case attendances. The incidence of basal cell carcinoma among the Hong Kong Chinese population in 1990 and 1999 was 0.32 and 0.92 per 100,000, respectively, whereas that of squamous cell carcinoma was 0.16 and 0.34 per 100,000, respectively. Demographic data and the site distribution of non-melanoma skin cancer were comparable to those reported in Caucasians living in North America and Europe, but different from those in Caucasians living in Australia and Hawaii. Pigmented basal cell carcinoma was the most common type of non-melanoma skin cancer (60.1%) in Chinese patients, in contrast with rodent ulceration in Caucasian. Multiple skin cancers, recurrence, and subsequent new skin cancers were less frequently observed than in studies of Caucasians. CONCLUSION: When compared with reported findings in Caucasians, Chinese patients show differences in the clinical type and multiplicity of lesions, predisposing factors, recurrence, and subsequent new skin cancer rates for non-melanoma skin cancer. Pigmented basal cell carcinoma seems to be an important differential diagnosis with regard to pigmented lesions in the Chinese population.