Report from the 67th annual meeting of the American Academy of Dermatology.

The 67th Annual Meeting of the American Academy of Dermatology took place in San Francisco on 6-10 March 2009. The flavour of this busy but well-organized convention was a mixture of practical, hands-on teaching sessions, led and delivered by experts, with breakthrough cutting-edge scientific sessions. Aesthetic dermatology comprised a significant part of the meeting. It is impossible to encompass all the important presentations made at the meeting and satellite symposiums, but we highlight here a few medical pearls on dermoscopy, melanoma and oncology, inflammatory dermatoses and community-acquired methicillin-resistant Staphylococcus aureus. Our report is not intended as a substitute for reading the conference proceedings, educational session handouts, online updates and related references quoted in this article.

The use of dietary manipulation by parents of children with atopic dermatitis.

BACKGROUND: In 1989 we demonstrated that 71% of children referred to our paediatric dermatology clinic with atopic dermatitis (AD) had been subject to dietary manipulation by their parents in order to manage their disease. We have re-examined our clinic population to determine whether the documented rise in the use of complementary therapy in children with skin disease has been accompanied by a rise in dietary manipulation. OBJECTIVES: To qualify and quantify the usage of dietary manipulation in children with AD in secondary care. METHODS: A face-to-face structured questionnaire study of 100 children with AD. RESULTS: The mean age of the children interviewed was 7.3 years (median 5.9, range 0.6-17.1) and ethnic origin was 59% white, 35% Indo-Asian, 3% Afro-Caribbean and 3% mixed race. Seventy-five per cent of patients (75 of 100) had tried some form of dietary exclusion; the most common foods omitted were dairy products in 48% (36 of 75), eggs in 27% (20 of 75) and cow's milk in 25% (19 of 75). Forty-one per cent of patients (41 of 100) had tried some form of dietary supplementation. The most common dietary supplement was evening primrose oil in 59% (24 of 41), of whom 13% (three of 24) felt this had helped their skin. Only 51% (38 of 75) had consulted a doctor or dietician before commencing any dietary change, but 39% (29 of 75) felt that their skin had improved as a result of this dietary manipulation. CONCLUSIONS: In comparison with our previous study, the proportion of patients excluding foods from their diet had increased from 71% to 75%. The proportion of these dietary changes that are unsupervised has remained the same, as have the food types avoided. The proportion of patients who report that unsupervised dietary manipulation is beneficial has increased from 10% to 39%.

Nail dystrophy, an unusual presentation of incontinentia pigmenti.

We describe a 57-year-old woman with a history of nail dystrophy since the age of 11 years. Multiple nail clippings were negative and multiple empirical treatments for presumed onychomycosis were unsuccessful. The patient has a daughter with classical incontinentia pigmenti. Molecular genetic analysis was positive for the NEMO gene deletion on the X chromosome, confirming the diagnosis of incontinentia pigmenti. Nail dystrophy was the sole feature of the disease in our patient.

The use of complementary medicine in children with atopic dermatitis in secondary care in Leicester.

BACKGROUND: The use of 'complementary' or 'alternative' medicine continues to rise in patients with skin disease, especially in those with chronic, inflammatory dermatoses. OBJECTIVES: To qualify and quantify the usage of complementary medicine (CM) in children with atopic dermatitis (AD) in secondary care. METHODS: A face-to-face structured questionnaire study of 100 consecutive children with AD and their parent or guardian. RESULTS: The mean age of the children interviewed was 7.3 years (median age 6.0 years, range 0.6-17.1) and ethnic origin was 59% white, 35% Indian, 3% Afro-Caribbean and 3% mixed race. Forty-six of 100 patients (46%) had used, or were currently using, CM. Of the 54 patients who had not yet used CM, 17 of 54 (31%) said they intended to try this in the future. The most commonly used CM was Chinese herbal medicine by 20 of 46 patients (43% of those who had used CM), followed by herbal medicine (41%) and homeopathy (35%). Of 74 patients using CM, 26 (35%) felt their AD had improved while 39 of 74 (53%) reported that it had remained unchanged. Twenty-six of 46 (56%) CM users in this study would not recommend CM to other patients with AD. There was a strong association between the use of CM and ethnicity (P = 0.01). Half of the patients who had used CM (23 of 46) had used it on the recommendation of family or friends with skin disease, 17 of 46 (37%) from family or friends without skin disease and three of 46 (6%) each from health professionals or from the media or internet. Twenty-five of 46 (54%) of CM users did so because conventional treatment was not working, and eight of 46 (17%) because they were worried about the side-effects of conventional treatment. While 39 of 100 (39%) of all patients felt that CM was safer than conventional medicine, only 14 of 100 felt it was more efficacious. Fifty-one of 100 were happy to combine both types of treatment and 66 of 100 felt that CM should be available from the National Health Service. CONCLUSIONS: In a population of children with AD attending a teaching hospital clinic in Leicester, U.K., 63% use or intend to use CM. This use is associated with ethnicity.

Pimecrolimus: a review of pre-clinical and clinical data.

Pimecrolimus (Elidel) is a novel cell-selective inhibitor of inflammatory cytokines that has specifically been developed for the treatment of inflammatory skin diseases due to its favourable skin selective pharmacological profile. Therapeutic efficacy and safety of pimecrolimus cream 1% has been established in the short-term treatment and the long-term management of atopic eczema in clinical studies in adults, children and infants. It rapidly relieves pruritus, and redness and swelling disappear or are only mild in up to 70% of pimecrolimus treated patients during the first three weeks. When applied at the first signs and symptoms of atopic eczema, pimecrolimus has proven to prevent flare progression and to provide superior long-term disease control compared with a conventional treatment, based on reactive use of corticosteroids. Pimecrolimus cream 1% is well tolerated, even on sensitive areas such as the face and neck. Blood concentrations remain low, even when extensive body areas are treated and no clinically significant systemic effects have been observed during short- or long-term clinical studies with pimecrolimus.

Neonatal erythema multiforme major.

A 25-day-old neonate developed an unusual eruption with bullae and marked systemic symptoms. Investigation for bacterial, viral, autoimmune and immunobullous causes did not reveal any identifiable trigger and histological examination was highly suggestive of bullous erythema multiforme. Pulmonary infiltrates were noted late in the course of the disease. Differential diagnoses included bullous impetigo, primary herpes simplex infection, immunobullous disease, neonatal lupus and erythema multiforme. This case illustrates the difficulties in diagnosing and managing an unwell child with bullae and emphasizes the need to exclude treatable underlying causes.

Atopic dermatitis management: comparing the treatment patterns of dermatologists in Japan, U.S.A. and U.K.

BACKGROUND: The incidence of atopic dermatitis (AD) is increasing worldwide. No large-scale study has previously compared the therapeutic management of this condition in different countries. OBJECTIVES: The purpose of this study was to determine the treatment preferences of dermatologists in Japan, the U.S.A. and the U.K., and investigate their relationship with certain factors pertaining to the physician and his practice. METHODS: A questionnaire was sent to all registered members of dermatological societies in Japan, the U.S.A. and the U.K. Responses were collated and statistical analysis performed using chi2, Mantel-Haenszel and Breslow heterogeneity tests. RESULTS: Three thousand six hundred and eighty-eight completed surveys were returned. U.S.A. and U.K. physicians were significantly more aggressive in prescribing systemic medications, such as steroids, antibiotics and immunosuppressants, compared with those in Japan. Japanese dermatologists also utilized topical steroids significantly less. The use of alternative remedies was highest in Japan. All three countries had a relatively high degree of optimism for topical immunosuppressants, but less so for other emerging therapies. CONCLUSIONS: Both similarities and differences in the therapy of AD exist in the three countries studied. Factors related to the physician, patient population and culture may influence these observations.

Azathioprine in severe adult atopic dermatitis: a double-blind, placebo-controlled, crossover trial.

BACKGROUND: There is a limited range of treatments for severe atopic dermatitis (AD). Azathioprine has often been used but there has been no randomized controlled trial of this drug to confirm its efficacy in AD. OBJECTIVES: To establish or refute the efficacy of azathioprine in severe AD. To investigate the safety and tolerability of azathioprine in this patient population. METHODS: We performed a double-blind, randomized, placebo-controlled, crossover trial of azathioprine in adult patients with severe AD. Each treatment period was of 3 months' duration. Treatments were azathioprine 2.5 mg kg(-1) day(-1) and matched placebo. Disease activity was monitored using the SASSAD sign score. In addition, severity of pruritus, sleep disturbance and disruption of work/daytime activity were monitored using visual analogue scales. Adverse events were recorded and haematological and biochemical monitoring was performed. RESULTS: Thirty-seven subjects were enrolled, mean age 38 years (range 17-73). Sixteen were withdrawn, 12 during azathioprine treatment and four during placebo treatment. The SASSAD score fell by 26% during treatment with azathioprine vs. 3% on placebo (P < 0.01). Pruritus, sleep disturbance and disruption of work/daytime activity all improved significantly on active treatment but not on placebo. The difference in mean improvement between azathioprine and placebo was significant for disruption of work/daytime activity (P < 0.02) but not for pruritus or sleep disturbance. Gastrointestinal disturbances were reported by 14 patients during azathioprine treatment and four were withdrawn as a result of severe nausea and vomiting. Leukopenia was observed in two patients and deranged liver enzymes in eight during treatment with azathioprine. CONCLUSIONS: Azathioprine is an effective and useful drug in severe AD although it is not always well-tolerated. Monitoring of the full blood count and liver enzymes is advisable during treatment.

Anti-E-selectin is ineffective in the treatment of psoriasis: a randomized trial.

BACKGROUND: Skin-homing, memory T lymphocytes play an important role in the pathogenesis of psoriasis by interacting with the vascular addressin, E-selectin and trafficking into lesional skin. Thus an attractive option for targeted therapy of the disease would be blockade of skin-homing T cells with an antibody directed at E-selectin. OBJECTIVE: We performed a multicentre, randomized, placebo-controlled trial to investigate the clinical efficacy and side-effect profile of a humanized monoclonal antibody to E-selectin, CDP850, in the treatment of moderate to severe chronic plaque psoriasis. METHODS: Patients with moderate/severe chronic plaque psoriasis were selected for study. Nine male subjects (mean age 37 years, range 25-47) were given 20 mg kg-1 CDP850 intravenously as a single dose and four subjects (three males, one female; mean age 40 years, range 23-50) received placebo infusion. Clinical response to treatment was assessed using the psoriasis area and severity index (PASI). Skin biopsies were taken for immunohistochemical analysis at the baseline, pretreatment, visit and also at day 2 and weeks 1 and 4 postinfusion. RESULTS: The treatment was well-tolerated with a minimal side-effect profile. Plasma E-selectin levels were significantly decreased in those subjects who received CDP850 compared with those who had placebo for the entire study period. At the end of study (8 weeks postinfusion), there was no significant reduction in PASI from baseline for either the CDP850 or placebo-treated groups. Immunohistochemical analysis of biopsies taken from lesional psoriatic skin showed that 2 days after dosing with CDP850, staining for E-selectin was decreased, although not absent, on dermal vascular endothelial cells when compared with baseline (P < 0.01). This decrease in E-selectin expression was maintained 4 weeks after infusion (P < 0.05). It was not, however, accompanied by a significant reduction in numbers of neutrophils or lymphocytes in the dermis. There was a statistically significant increase in CD1a-positive epidermal Langerhans cells compared with pre-dose levels at week 1 (P < 0.05). CONCLUSIONS: This clinicopathological study shows that anti-E-selectin (CDP850), although a well-tolerated, logical and safe therapy, does not appear to possess a therapeutic role in the treatment of chronic plaque psoriasis.

Cyclosporin for severe childhood atopic dermatitis: short course versus continuous therapy.

Cyclosporin (CyA) has been shown to be highly effective and well tolerated in the short-term treatment of severe childhood atopic dermatitis; however, there is limited experience in its longer-term use. The aim of this study was to compare multiple short courses of CyA with continuous therapy for 1 year, with respect to efficacy, safety, tolerability and quality of life. Children aged 2-16 years, with a diagnosis of severe atopic dermatitis refractory to topical steroid therapy, were randomly assigned to receive short course therapy (multiple courses of 12 weeks) or continuous therapy. The starting dose and maximum dose for all patients was 5 mg/kg per day. Disease activity was monitored using the Six Area Six Sign Atopic Dermatitis score and the 'Rule of Nines' area score. Pruritus, sleep disturbance and irritability were measured using visual analogue scales, and topical therapy was monitored. Safety measurements included monitoring of serum creatinine, blood pressure and adverse events. Forty patients were included in the efficacy analysis, 21 of whom were randomized to the short course group (of whom six were withdrawn) and 19 to the continuous group (of whom five were withdrawn). Significant improvements were seen in all efficacy parameters at every time-point. There were no significant differences between groups, although the improvement was more consistent in the continuous arm. In the short course arm, 7 out of 21 patients could be managed by at least two short courses. The remaining 14 patients includes 12 who could not be controlled by at least two short courses, one patient who failed to return after week 12 and another patient who was withdrawn at week 4 due to an adverse event. Quality of life improved for both the children and their families. Tolerability was considered good or very good in at least 80% of the patients at week 12 and at the end of the study. No clinically significant change was seen in mean serum creatinine and no change was seen in mean blood pressure in either group. CyA is effective in controlling severe atopic dermatitis in children over a 1-year period and is well tolerated. More consistent control is achieved with continuous treatment; however, short course therapy was adequate for some patients, indicating that treatment should be tailored to the individual patient's needs. Short course treatment may produce prolonged remission in some cases and reduce the cumulative exposure to the drug.