Treatment of acquired reactive perforating dermatosis - a systematic review.

Reactive perforating dermatosis is a rare chronic skin disease defined by the transepidermal elimination of collagen and/or elastin. In the acquired form in adults, it is frequently associated with diseases such as diabetes and chronic renal failure. No systematic reviews of treatment options are available for this disease. The aim of this systematic review is to summarize all reported treatment options for acquired reactive perforating dermatosis (ARPD). This is a systematic review based on a MEDLINE search of articles in English and German from 1990 to 2016. Most medical literature on the treatment of ARPD is limited to individual case reports and small series of patients. Various therapies that have been tried include antihistamines, topical keratolytics, corticosteroids, tretinoin, oral drugs such as allopurinol or antibiotics, and phototherapy or photochemotherapy. While there are no specific criteria for the evidence-based selection of treatment options for ARPD, the first priority in management of these conditions should be treatment of an underlying disease if present. None of the described modalities has been approved for first-line therapy. It is recommended to choose a combination of drugs that reduce itching and assist in the resolution of the skin lesions at the same time.

Interventions for preventing occupational irritant hand dermatitis.

BACKGROUND: Occupational irritant hand dermatitis (OIHD) causes significant functional impairment, disruption of work, and discomfort in the working population. Different preventive measures such as protective gloves, barrier creams and moisturisers can be used, but it is not clear how effective these are. This is an update of a Cochrane review which was previously published in 2010. OBJECTIVES: To assess the effects of primary preventive interventions and strategies (physical and behavioural) for preventing OIHD in healthy people (who have no hand dermatitis) who work in occupations where the skin is at risk of damage due to contact with water, detergents, chemicals or other irritants, or from wearing gloves. SEARCH METHODS: We updated our searches of the following databases to January 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLlNE, and Embase. We also searched five trials registers and checked the bibliographies of included studies for further references to relevant trials. We handsearched two sets of conference proceedings. SELECTION CRITERIA: We included parallel and cross-over randomised controlled trials (RCTs) which examined the effectiveness of barrier creams, moisturisers, gloves, or educational interventions compared to no intervention for the primary prevention of OIHD under field conditions. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. The primary outcomes were signs and symptoms of OIHD developed during the trials, and the frequency of treatment discontinuation due to adverse effects. MAIN RESULTS: We included nine RCTs involving 2888 participants without occupational irritant hand dermatitis (OIHD) at baseline. Six studies, including 1533 participants, investigated the effects of barrier creams, moisturisers, or both. Three studies, including 1355 participants, assessed the effectiveness of skin protection education on the prevention of OIHD. No studies were eligible that investigated the effects of protective gloves. Among each type of intervention, there was heterogeneity concerning the criteria for assessing signs and symptoms of OIHD, the products, and the occupations. Selection bias, performance bias, and reporting bias were generally unclear across all studies. The risk of detection bias was low in five studies and high in one study. The risk of other biases was low in four studies and high in two studies.The eligible trials involved a variety of participants, including: metal workers exposed to cutting fluids, dye and print factory workers, gut cleaners in swine slaughterhouses, cleaners and kitchen workers, nurse apprentices, hospital employees handling irritants, and hairdressing apprentices. All studies were undertaken at the respective work places. Study duration ranged from four weeks to three years. The participants' ages ranged from 16 to 67 years.Meta-analyses for barrier creams, moisturisers, a combination of both barrier creams and moisturisers, or skin protection education showed imprecise effects favouring the intervention. Twenty-nine per cent of participants who applied barrier creams developed signs of OIHD, compared to 33% of the controls, so the risk may be slightly reduced with this measure (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.72 to 1.06; 999 participants; 4 studies; low-quality evidence). However, this risk reduction may not be clinically important. There may be a clinically important protective effect with the use of moisturisers: in the intervention groups, 13% of participants developed symptoms of OIHD compared to 19% of the controls (RR 0.71, 95% CI 0.46 to 1.09; 507 participants; 3 studies; low-quality evidence). Likewise, there may be a clinically important protective effect from using a combination of barrier creams and moisturisers: 8% of participants in the intervention group developed signs of OIHD, compared to 13% of the controls (RR 0.68, 95% CI 0.33 to 1.42; 474 participants; 2 studies; low-quality evidence). We are uncertain whether skin protection education reduces the risk of developing signs of OIHD (RR 0.76, 95% CI 0.54 to 1.08; 1355 participants; 3 studies; very low-quality evidence). Twenty-one per cent of participants who received skin protection education developed signs of OIHD, compared to 28% of the controls.None of the studies addressed the frequency of treatment discontinuation due to adverse effects of the products directly. However, in three studies of barrier creams, the reasons for withdrawal from the studies were unrelated to adverse effects. Likewise, in one study of moisturisers plus barrier creams, and in one study of skin protection education, reasons for dropout were unrelated to adverse effects. The remaining studies (one to two in each comparison) reported dropouts without stating how many of them may have been due to adverse reactions to the interventions. We judged the quality of this evidence as moderate, due to the indirectness of the results. The investigated interventions to prevent OIHD probably cause few or no serious adverse effects. AUTHORS' CONCLUSIONS: Moisturisers used alone or in combination with barrier creams may result in a clinically important protective effect, either in the long- or short-term, for the primary prevention of OIHD. Barrier creams alone may have slight protective effect, but this does not appear to be clinically important. The results for all of these comparisons were imprecise, and the low quality of the evidence means that our confidence in the effect estimates is limited. For skin protection education, the results varied substantially across the trials, the effect was imprecise, and the pooled risk reduction was not large enough to be clinically important. The very low quality of the evidence means that we are unsure as to whether skin protection education reduces the risk of developing OIHD. The interventions probably cause few or no serious adverse effects.We conclude that at present there is insufficient evidence to confidently assess the effectiveness of interventions used in the primary prevention of OIHD. This does not necessarily mean that current measures are ineffective. Even though the update of this review included larger studies of reasonable quality, there is still a need for trials which apply standardised measures for the detection of OIHD in order to determine the effectiveness of the different prevention strategies.

Occupational contact urticaria caused by food - a systematic clinical review.

Food industry workers are at increased risk for occupational contact urticaria (CU). There are many foodstuffs that have been reported to cause occupational CU, including seafood, meat, vegetables, and fruits. The aim of this review is to summarize all reported occupational cases of CU in the food industry. This is a systematic review based on a MEDLINE search of articles in English and German and a manual search, between 1990 and 2014, to summarize the case reports and case series of occupational CU in the food industry. Many different foodstuffs have been implicated in CU. Occupational CU has been reported in many different occupations, mostly in individuals dealing with seafood, meat, vegetables, and fruits, such as chefs, cooks, bakers, butchers, slaughterhouse workers, and fish-factory workers. Foodstuffs that commonly induce occupational protein contact dermatitis include fish, seafood, meats, vegetables, and fruits. Food handlers may acquire CU resulting from occupational exposures. The prognosis varies widely. The diagnosis of immunological CU is based on the clinical history and on a positive prick test with the suspected substance and/or measurement of specific IgE.

Lichen planus and lichenoid reactions as a systemic disease.

Lichen planus (LP) is a chronic disease that involves the skin, scalp, mucous membranes, and nails. The etiology of LP is still unknown; however, some external and internal factors (eg. drugs, stress, hepatitis C virus) have been suggested to trigger the disease. Many studies have investigated an immunologic pathogenesis that is probably related to T-cell autoimmunity with the keratinocyte as the target cell. Altered self-antigens on the surface of basal keratinocytes modified by viruses or by drugs are believed to be the targets of the T-cell response. Various drugs and contact allergens like amalgam may cause lichenoid reactions, which are the main differential diagnoses of LP. Clinically and histologically, LP and lichenoid reactions cannot be distinguished with certainty in many cases. Treatment is mainly symptomatic and can be difficult. The first-line therapies for LP are topical or systemic corticosteroids; however, some studies have mentioned acitretin leading to similar improvement. Medical treatment, together with patient education and psychosocial support, can significantly benefit patients' quality of life.

Molecular clues of a microepidemy among homeless tuberculosis patients in Budapest due to a new and local Mycobacterium tuberculosis clade.

In Budapest, the capital of Hungary, one of the most important tuberculosis related risk factors is homelessness. The aim of this retrospective study was the genetic characterization of Mycobacterium tuberculosis strains isolated from 66 homeless tuberculosis patients by spoligotyping and mycobacterial interspersed repetitive unit (MIRU) typing. The study identified a local microepidemy in the district with the highest tuberculosis incidence of Budapest. Further genetic characterization has shown that the microepidemy was due to a locally emerged Budapest-specific lineage of M. tuberculosis. These data may serve as a reference to better monitor and understand the patterns and transmission dynamics of tuberculosis in this at-risk population and is the first report on genetic diversity of M. tuberculosis in today's Hungarians. The findings also indicate that tuberculosis control and prevention steps among the homeless need to be strengthened.

[Micro-epidemic due to a new Mycobacterium tuberculosis strain among the homeless in Budapest, Hungary]. / Uj Mycobacterium tuberculosis törzs okozta mikroepidémia budapesti hajléktalanokban.

In a retrospective study that included 66 homeless tuberculosis patients a local micro-epidemic was identified in the VIIIth district of Budapest with the highest tuberculosis incidence of the capital. Further molecular genetic characterization by IS 6110 fingerprinting, spoligotyping and mycobacterial inter-spread repetitive unit (MIRU) typing has shown that the observed micro-epidemic was due to a locally emerged, Budapest-specific lineage. The absence of infections with the more virulent Beijing genotype is also noteworthy. The findings indicate that tuberculosis control and prevention steps among the homeless need to be strengthened in Hungary.

Molecular epidemiology of drug-resistant tuberculosis in Hungary.

Sixty-eight drug-resistant Mycobacterium tuberculosis isolates (44.2% of all resistant cases) were analyzed by IS6110 restriction fragment length polymorphism fingerprinting and spoligotyping to provide a deeper insight into the status of drug-resistant tuberculosis in Hungary. A total of 54.4% of the drug-resistant cases and 75% of the multidrug-resistant cases could be clustered. Analysis of the spoligotyping patterns of the strains revealed a high rate (66.2%) of infection by the Haarlem genotype, while none of the patients were infected by the Beijing genotype. The magnitude and the dynamics of drug-resistant tuberculosis are underestimated in Hungary.

[Tuberculosis due to multidrug resistant Mycobacterium tuberculosis Beijing genotype identified by DNA fingerprinting: the first case identified in Hungary]. / DNS ujjlenyomat-vizsgálattal azonosított Beijing genotípusú Mycobacterium tuberculosis okozta multidrog rezisztens tuberculosis: az elso Magyarországon igazolt eset.

In a 28 years old Mongolian woman in whom pulmonary tuberculosis was diagnosed a poly- and multidrug (isoniazid, rifampicin, pyrazinamide, ethambutol, streptomycin) resistant Mycobacterium tuberculosis was isolated from sputum in 2002. Since the patient was from a country with high tuberculosis incidence it was conceivable that she had been infected by a strain with primary resistance in Mongolia. In order to confirm the origin of the strain an IS6110-based DNA fingerprint test was performed on the isolate. The assay revealed that the isolated M. tuberculosis strain belonged to the so-called Beijing family which was never detected in Hungary before.

Conventional and molecular epidemiology of tuberculosis in homeless patients in Budapest, Hungary.

In Hungary the incidence of tuberculosis among the homeless population was 676 per 100,000 in 2002. Sixty-nine percent (140 patients) of all homeless tuberculosis patients were notified in Budapest (the capital). Therefore, a retrospective study that included 66 homeless tuberculosis patients notified in Budapest in 2002 was conducted to determine the rate of recent transmission of the disease and medical risk factors and to identify transmission pathways by means of conventional and molecular epidemiologic methods. IS6110 DNA fingerprinting revealed that 71.2% of the isolates could be clustered. Thirty-four (51.5%) patients belonged to five major clusters (size, from 4 to 11 individuals), and 13 (19.7%) belonged to six smaller clusters. Additional analysis of patient records found that 2 (18%) of the 11 patients in cluster A, 3 (37.5%) of the 8 patients in cluster B, and 2 (33%) of the 6 patients in cluster C were residents of the same three homeless shelters during the diagnosis of tuberculosis. Review of the database of the National Tuberculosis Surveillance Center (NTSC) revealed that 21.2% of the cases have not been reported to the NTSC. These findings indicate that the screening and treatment of tuberculosis among the homeless need to be strengthened and also warrant the review of environmental control steps in public shelters. Improvement of adherence of clinicians to surveillance reporting regulations is also necessary.