Clinical severity and prognosis of hand eczema.

BACKGROUND: Hand eczema (HE) is a frequent, long-lasting disease with both personal and societal repercussions. Consequently, more information is needed on factors that maintain symptoms. OBJECTIVES: In this study, patients with HE were followed for 6 months from the first visit to a dermatologist to identify factors associated with severe disease and a poor prognosis. METHODS: Study participants were 799 patients with HE from nine dermatological clinics in Denmark. Severity assessment of the HE was done at baseline and at the 6-month follow-up using the Hand Eczema Severity Index (HECSI) and by patients using a self-administered photographic guide. Additional information was obtained from a baseline questionnaire. RESULTS: At baseline, 60.3% assessed their HE as moderate to very severe using the self-administered photographic guide compared with 36.1% at follow-up. The mean HECSI value decreased from 19.9 points at baseline to 11.2 points at follow-up (P < 0.001). In a multivariable logistic regression analysis, statistically significant associations with severe HE at baseline were older age (P < 0.001), atopic dermatitis (P = 0.01) and > or = 1 positive patch test (P < 0.001). Being an unskilled worker was a predictor for a poor prognosis at follow-up (P = 0.04), and the presence of frequent symptoms during the previous 12 months was associated with severe initial disease (P = 0.02) and a poor prognosis (P = 0.04). CONCLUSIONS: Overall, the disease had improved 6 months after the dermatological examination: nevertheless, many patients continued to have significant symptoms. Dermatologists should pay special attention to patients with frequent eruptions and to unskilled workers.

Severity of hand eczema assessed by patients and dermatologist using a photographic guide.

BACKGROUND: The severity of hand eczema is of interest in epidemiological studies. Ideally, as no validated methods of self-assessment exist, a dermatologist should examine all subjects. However, this is very resource intensive. OBJECTIVES: To examine if severity grading performed by patients with hand eczema using a self-administered photographic guide was in agreement with the assessment performed by a trained dermatologist. Furthermore, to measure the correlation between the severity of hand eczema expressed on a visual analogue scale (VAS) and the clinical severity assessment, using the photographic guide. METHODS: Fifty-three consecutive outpatients with hand eczema were included, a number based on a prestudy statistical calculation. The patients were asked to grade current severity of their hand eczema by choosing one of four groups of photographs representing differing severities of hand eczema. On the same day all patients were examined by an experienced dermatologist, who graded the severity using the same photographic guide. The photographic guide was a modified version of a validated guide for use by physicians. In addition, the patients rated the severity of their hand eczema on a VAS. RESULTS: Fifty-one of the respondents completed the full questionnaire. For 37 of the 51 patients (73%) the clinical severity assessments of patient and dermatologist were identical. The measure of agreement, Cohen's kappa coefficient, was 0.61, indicating good inter-rater agreement. The correlation between the dermatologist-rated severity and the corresponding score by the patients on the VAS was only moderate (Spearman's rank correlation coefficient rho = 0.52). CONCLUSIONS: The photographic guide for the self-assessment of hand eczema is an easy instrument to use, and for research purposes can be a reliable tool for patients with hand eczema to grade severity. A VAS can only be considered as a mediocre tool for estimation of the dermatologist-rated clinical severity, but should be validated as an independent instrument to assess severity of hand eczema.

Treatment of hand eczema.

Hand eczema is a common skin disease that tends to become chronic and may interfere with many types of work. Emollients have been shown to be useful in reducing eczema activity and in the primary prevention of hand eczema. Protection of the hands is very important for the prevention of hand eczema and is a fundamental aspect of the treatment of hand eczema. Although topical corticosteroids are the mainstay of treatment, few studies of their rational use, efficacy and side-effects have been conducted. A combination of tacrolimus and topical corticosteroids may reduce the risk of steroid-associated side-effects. Systemic treatment with immunosuppressants such as cyclosporine and methotrexate show promising results, and acitretin may suppress keratotic hand eczema. Botulinum toxin has been used with success in the treatment of dyshidrotic hand eczema. PUVA is effective as a systemic treatment. Bath-PUVA treatment, UVB and Grenz rays can also suppress hand eczema.

Reduced nickel sensitivity in young Danish women following regulation of nickel exposure.

In most western countries, nickel is the most common contact allergen among young women. In 1991, Denmark implemented a statutory order calling for the reduction of exposure to nickel in nickel-plated items in close contact with the skin. In a retrospective analysis, a comparison is made of the number of positive patch tests to nickel seen in a private practice of dermatology before and after this statutory order was implemented. From 1 January 1986 to 31 December 1989, 35 of 1135 (3.1%) men patch tested and 628 of 3024 (20.8%) women patch tested had positive reactions to nickel. From 1 January 1996 to 31 December 1999, 48 of 1104 (4.3%) men and 424 of 2193 (19.3%) women had positive patch tests to nickel. During the 1st period, 155 of 702 women under the age of 20 (22.1%) had positive patch tests to nickel, compared to 54 of 324 (16.7%) during the second period (p<0.05). The most likely explanations of this decrease in nickel sensitivity are reduced exposure to nickel and increased public awareness of the risk of nickel sensitization.

Brachioradial pruritus.

Twenty-one patients seen in a temperate climate who had a clinical diagnosis of brachioradial pruritus are presented. The history and clinical manifestations of the patients indicate that the symptoms were neuralgiform and caused by cumulative sun exposure.

Treatment of hyperkeratotic dermatitis of the palms (eczema keratoticum) with oral acitretin. A single-blind placebo-controlled study.

Hyperkeratotic dermatitis of the palms--also called eczema keratoticum--is a chronic, sometimes disabling condition in middle-aged persons. We carried out a single-blind, placebo-controlled study using acitretin in 29 patients. Fourteen patients received active therapy (30mg acitretin daily) and 15 placebo. All had hyperkeratotic changes of the palms with painful fissures and most had involvement of the volar aspects of their fingers. Approximately half of the patients had similar plantar changes. A semi-quantitative score of six parameters was used: hyperkeratosis, fissuring, scaling, itch, redness and vesicle count. After 4 weeks of treatment, a 51% reduction of all symptoms was observed among patients receiving acitretin (p < 0.01) compared with a 9% reduction in the placebo group (p>0.05). No further improvement was seen over another 4 weeks of treatment. There were no changes in blood biochemistry, including serum lipids. No patients discontinued therapy because of side effects. We conclude that 30 mg of acitretin is efficacious and safe to use in patients with hyperkeratotic dermatitis of the palms.

[Keratin diseases]. / Keratinsygdomme.

The rapid development in human genome research has resulted in a tremendous increase in our understanding of the molecular basis of many genetic skin diseases. One outstanding example of this is diseases caused by mutations in keratin genes, which comprise several disorders of the epidermis, as for example the different types of epidermolysis bullosa simplex. In this respect, the most important questions have been to 1. Define the molecular defect. 2. Unravel the pathophysiological mechanisms that lead to the characteristic phenotype and 3. Design of new therapeutic strategies. Molecular research has contributed significantly to the first two issues whereas a therapeutic break-through has yet to appear.

[Epidermolysis bullosa simplex: genotype-phenotype correlation in Danish patients]. / Epidermolysis bullosa simplex: korrelation mellem genotype og faenotype hos danske patienter.

Epidermolysis bullosa simplex (EBS) is a group of autosomal dominant inherited skin disorders caused by mutations in the keratin genes K5 or K14. We examined five Danish families with EBS-Weber-Cockayne (WC) or EBS-Koebner (K) and two sporadic cases of EBS-Dowling-Meara (DM) in order to investigate the mutational spectrum and evaluate the genotype-phenotype correlation in Danish patients. Three new K14 mutations, one new and one previously described K5 mutation were identified by DNA sequence analysis. The positions of the EBS-DM mutations were consistent with previous studies, whereas the EBS-WC and EBS-K mutations were found in regions of the keratin genes not typically associated with this type of EBS mutations. In conclusion, we found a strict genotype-phenotype correlation. Furthermore, we found that the position of the mutation in the keratin gene is not the only determinant for severity of the disease; the nature of the amino acid substitution should also be considered when predicting the severity of the EBS disorder.

Long-term, intermittent treatment of chronic hand eczema with mometasone furoate.

Chronic hand eczema can be incapacitating, and there is little knowledge of the efficacy and safety of long-term treatment with topical corticosteroids. We compared the efficacy and safety of two different schedules for the treatment of chronic hand eczema with a potent topical corticosteroid, mometasone furoate. In a prospective, open, randomized trial, 120 patients with chronic hand eczema were treated daily with mometasone furoate fatty cream until the dermatitis cleared or for a maximum of 9 weeks. Those who cleared were randomized to treatment for up to 36 weeks with mometasone furoate on Sunday, Tuesday and Thursday (group A), mometasone furoate on Saturday and Sunday (group B) or no further corticosteroid treatment (group C). In the event of relapse, patients were permitted daily treatment with mometasone furoate for 3 weeks on two separate occasions. For 50 of 106 randomized patients, daily treatment for 3 weeks controlled their dermatitis; 29 needed 6 weeks and 27 needed 9 weeks of treatment. During the maintenance phase, 29 of 35 (83%) in group A, 25 of 37 (68%) in group B and nine of 34 (26%) in group C had no recurrences (P = 0.001, chi2-test). Side-effects were minimal. It is concluded that long-term, intermittent treatment of chronic hand eczema with mometasone furoate fatty cream is effective and safe.

Identification of novel and known mutations in the genes for keratin 5 and 14 in Danish patients with epidermolysis bullosa simplex: correlation between genotype and phenotype.

Epidermolysis bullosa simplex (EBS) is a group of autosomal dominant inherited skin diseases caused by mutations in either the keratin 5 (K5) or the keratin 14 (K14) genes and characterized by development of intraepidermal skin blisters. The three major subtypes of EBS are Weber-Cockayne, Koebner, and Dowling-Meara, of which the Dowling-Meara form is the most severe. We have investigated five large Danish families with EBS and two sporadic patients with the Dowling-Meara form of EBS. In the sporadic Dowling-Meara EBS patients, a novel K14 mutation (N123S) and a previously published K5 mutation (N176S) were identified, respectively. A novel K14 mutation (K116N) was found in three seemingly unrelated families, whereas another family harbored a different novel K14 mutation (L143P). The last family harbored a novel K5 mutation (L325P). The identified mutations were not present in more than 100 normal chromosomes. Six polymorphisms were identified in the K14 gene and their frequencies were determined in normal controls. These polymorphisms were used to show that the K14 K116N mutation was located in chromosomes with the same haplotype in all three families, suggesting a common ancestor. We observed a strict genotype-phenotype correlation in the investigated patients as the same mutation always resulted in a similar phenotype in all individuals with the mutation, but our results also show that it is not possible to predict the EBS phenotype merely by the location (i.e., head, rod, or linker domains) of a mutation. The nature of the amino acid substitution must also be taken into account.

The clinician's choice of antibiotics in the treatment of bacterial skin infection.

The development of modern antibiotics has vastly improved the therapy of cutaneous bacterial infections, particularly those caused by Staphylococcus aureus. This organism and beta-haemolytic streptococci are the most common cutaneous pathogens. A growing body of evidence suggests that proteins from S. aureus and some strains of streptococci can act as superantigens and cause polyclonal T-cell activation by binding directly to antigen-presenting cells. This process is a likely explanation of Kawasaki's syndrome as well as staphylococcal and streptococcal toxic shock syndrome. Sudden aggravation of atopic dermatitis, contact dermatitis and some cases of psoriasis can be similarly explained. Bacterial toxins can precipitate the staphylococcal scalded skin syndrome. Specific and effective eradication of bacteria and programmes to prevent recurrences are important, particularly in immune suppressed persons. Topical antibiotics used primarily for superficial infections of limited extent and for the prevention of recurrences in carriers of S. aureus should be combined with the use of topical disinfectants. The treatment of selected bacterial skin infections based on clinical examples will be discussed. These include secondarily infected dermatoses, cellulitis and streptococcal carriage in the ano-genital region and staphylococcal folliculitis and nasal carriage.

Once daily treatment of psoriasis with tacalcitol compared with twice daily treatment with calcipotriol. A double-blind trial.

Once daily topical treatment of psoriasis with tacalcitol ointment (4 micrograms/g) was compared with twice daily treatment with calcipotriol ointment (50 micrograms/g) in a double-blind, randomized study over a treatment period of 8 weeks. The severity of pruritus, erythema, infiltration and scaling was scored on a scale from 0 to 4. These features were scored at the initiation of treatment, after 2, 4, 6 and 8 weeks of treatment, and at 4 weeks after discontinuation of treatment. The sum score was the total score for erythema, infiltration and scaling. Serum levels of calcium, phosphate, ionized calcium and intact parathyroid hormone were used as safety parameters. Two hundred and eighty-seven adults with stable plaque psoriasis participated and were treated at least once. Both tacalcitol and calcipotriol ointments effectively reduced the severity of psoriasis. The mean reduction in the sum score in the intention-to-treat population of 287 patients was 4.03 in the group treated with tacalcitol compared with 5.05 in the group treated with calcipotriol. The mean baseline sum scores were 7.64 and 7.15, respectively. The acceptability of both ointments was excellent, and none of the patients had adverse effects in terms of increased serum calcium or other alterations in calcium metabolism. Although less effective than calcipotriol ointment used twice daily, tacalcitol ointment is an effective and useful once daily treatment of chronic plaque psoriasis.