Psychological and educational interventions for managing eczema

Objectives: This is a protocol for a Cochrane Review (intervention). The objectives are as follows:. 1. To assess the clinical outcomes of psychological and educational interventions in children and adults with eczema. 2. To summarise the availability and principal findings of relevant economic evaluations

Topical antifungal treatments for tinea cruris and tinea corporis (Protocol)

To assess the effects of topical antifungal treatments and whether combination products, e.g. those containing topical corticosteroids plus antifungals, are any better than topical antifungals alone for treating tinea corporis and tinea cruris infections in men and women

Topical antifungal treatments for tinea cruris and tinea corporis

BackgroundTinea infections are fungal infections of the skin caused by dermatophytes. It is estimated that 10% to 20% of the world population is affected by fungal skin infections. Sites of infection vary according to geographical location, the organism involved, and environmental and cultural differences. Both tinea corporis, also referred to as 'ringworm' and tinea cruris or 'jock itch' are conditions frequently seen by primary care doctors and dermatologists. The diagnosis can be made on clinical appearance and can be confirmed by microscopy or culture. A wide range of topical antifungal drugs are used to treat these superficial dermatomycoses, but it is unclear which are the most effective.ObjectivesTo assess the effects of topical antifungal treatments in tinea cruris and tinea corporis.Search methodsWe searched the following databases up to 13th August 2013: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2013, Issue 7), MEDLINE (from 1946), EMBASE (from 1974), and LILACS (from 1982). We also searched five trials registers, and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials. We handsearched the journal Mycoses from 1957 to 1990.Selection criteriaRandomised controlled trials in people with proven dermatophyte infection of the body (tinea corporis) or groin (tinea cruris).Data collection and analysisTwo review authors independently carried out study selection, data extraction, assessment of risk of bias, and analyses.Main resultsOf the 364 records identified, 129 studies with 18,086 participants met the inclusion criteria. Half of the studies were judged at high risk of bias with the remainder judged at unclear risk. A wide range of different comparisons were evaluated across the 129 studies, 92 in total, with azoles accounting for the majority of the interventions. Treatment duration varied from one week to two months, but in most studies this was two to four weeks. The length of follow-up varied from one week to six months. Sixty-three studies contained no usable or retrievable data mainly due to the lack of separate data for different tinea infections. Mycological and clinical cure were assessed in the majority of studies, along with adverse effects. Less than half of the studies assessed disease relapse, and hardly any of them assessed duration until clinical cure, or participant-judged cure. The quality of the body of evidence was rated as low to very low for the different outcomes.Data for several outcomes for two individual treatments were pooled. Across five studies, significantly higher clinical cure rates were seen in participants treated with terbinafine compared to placebo (risk ratio (RR) 4.51, 95% confidence interval (CI) 3.10 to 6.56, number needed to treat (NNT) 3, 95% CI 2 to 4). The quality of evidence for this outcome was rated as low. Data for mycological cure for terbinafine could not be pooled due to substantial heterogeneity.Mycological cure rates favoured naftifine 1% compared to placebo across three studies (RR 2.38, 95% CI 1.80 to 3.14, NNT 3, 95% CI 2 to 4) with the quality of evidence rated as low. In one study, naftifine 1% was more effective than placebo in achieving clinical cure (RR 2.42, 95% CI 1.41 to 4.16, NNT 3, 95% CI 2 to 5) with the quality of evidence rated as low.Across two studies, mycological cure rates favoured clotrimazole 1% compared to placebo (RR 2.87, 95% CI 2.28 to 3.62, NNT 2, 95% CI 2 to 3).Data for several outcomes were pooled for three comparisons between different classes of treatment. There was no difference in mycological cure between azoles and benzylamines (RR 1.01, 95% CI 0.94 to 1.07). The quality of the evidence was rated as low for this comparison. Substantial heterogeneity precluded the pooling of data for mycological and clinical cure when comparing azoles and allylamines. Azoles were slightly less effective in achieving clinical cure compared to azole and steroid combination creams immediately at the end of treatment (RR 0.67, 95% CI 0.53 to 0.84, NNT 6, 95% CI 5 to 13), but there was no difference in mycological cure rate (RR 0.99, 95% CI 0.93 to 1.05). The quality of evidence for these two outcomes was rated as low for mycological cure and very low for clinical cure.All of the treatments that were examined appeared to be effective, but most comparisons were evaluated in single studies. There was no evidence for a difference in cure rates between tinea cruris and tinea corporis. Adverse effects were minimal - mainly irritation and burning; results were generally imprecise between active interventions and placebo, and between different classes of treatment.Authors' conclusionsThe pooled data suggest that the individual treatments terbinafine and naftifine are effective. Adverse effects were generally mild and reported infrequently. A substantial number of the studies were more than 20 years old and of unclear or high risk of bias; there is however, some evidence that other topical antifungal treatments also provide similar clinical and mycological cure rates, particularly azoles although most were evaluated in single studies.There is insufficient evidence to determine if Whitfield’s ointment, a widely used agent is effective.Although combinations of topical steroids and antifungals are not currently recommended in any clinical guidelines, relevant studies included in this review reported higher clinical cure rates with similar mycological cure rates at the end of treatment, but the quality of evidence for these outcomes was rated very low due to imprecision, indirectness and risk of bias. There was insufficient evidence to confidently assess relapse rates in the individual or combination treatments.Although there was little difference between different classes of treatment in achieving cure, some interventions may be more appealing as they require fewer applications and a shorter duration of treatment. Further, high quality, adequately powered trials focusing on patient-centred outcomes, such as patient satisfaction with treatment should be considered

Observed 20th century desert dust variability: impact on climate and biogeochemistry

Desert dust perturbs climate by directly and indirectly interacting with incoming solar and outgoing long wave radiation, thereby changing precipitation and temperature, in addition to modifying ocean and land biogeochemistry. While we know that desert dust is sensitive to perturbations in climate and human land use, previous studies have been unable to determine whether humans were increasing or decreasing desert dust in the global average. Here we present observational estimates of desert dust based on paleodata proxies showing a doubling of desert dust during the 20th century over much, but not all the globe. Large uncertainties remain in estimates of desert dust variability over 20th century due to limited data. Using these observational estimates of desert dust change in combination with ocean, atmosphere and land models, we calculate the net radiative effect of these observed changes (top of atmosphere) over the 20th century to be −0.14 ± 0.11 W/m2 (1990–1999 vs. 1905–1914). The estimated radiative change due to dust is especially strong between the heavily loaded 1980–1989 and the less heavily loaded 1955–1964 time periods (−0.57 ± 0.46 W/m2), which model simulations suggest may have reduced the rate of temperature increase between these time periods by 0.11 °C. Model simulations also indicate strong regional shifts in precipitation and temperature from desert dust changes, causing 6 ppm (12 PgC) reduction in model carbon uptake by the terrestrial biosphere over the 20th century. Desert dust carries iron, an important micronutrient for ocean biogeochemistry that can modulate ocean carbon storage; here we show that dust deposition trends increase ocean productivity by an estimated 6% over the 20th century, drawing down an additional 4 ppm (8 PgC) of carbon dioxide into the oceans. Thus, perturbations to desert dust over the 20th century inferred from observations are potentially important for climate and biogeochemistry, and our understanding of these changes and their impacts should continue to be refined

Educational and psychological interventions for managing atopic dermatitis

Background Atopic dermatitis can have a significant impact on well-being and quality of life for affected people and their families. Standard treatment is with trigger/irritant avoidance and regular application of emollients and topical steroids or calcineurin inhibitors. Thorough physical and psychological assessment is central to informing about good quality treatment. Overcoming barriers to provision of holistic treatment in dermatological practice is dependent on evaluation of the efficacy and economics of both psychological and educational interventions in this participant group. Objectives 1. To assess the clinical outcomes of educational and psychological interventions in children and adults with atopic dermatitis 2. To summarise the availability and principal findings of relevant economic evaluations Search Methods The Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, APA PsycINFO and two trials registers were searched up to March 2023. We checked the reference lists of included studies and related systematic reviews for further references to relevant randomised controlled trials (RCTs) and contacted experts in the field to identify additional studies. NHS EED, MEDLINE and Embase were searched for economic evaluations on 8 June 2022. Selection criteria Randomised, cluster‐randomised and crossover randomised controlled trials that assess educational and psychological interventions for treating atopic dermatitis in children and adults. Data collection and Analysis We used standard Cochrane methods, with GRADE to assess the quality of the evidence for each outcome. Primary outcomes were reduction in disease severity, as measured by clinical signs, patient‐reported symptoms and improvement in quality‐of‐life measures. Secondary outcomes were improvement in long‐term control of atopic dermatitis symptoms, improvement in psychological well‐being, improvement in standard treatment concordance and adverse events. Time points assessed were short term (up to 16 weeks after treatment) and long term (>16 weeks). Main results We included 37 trials (6170 participants). Most trials were conducted in high‐income countries (34/37), in outpatient settings (25/37). We judged three trials to be low risk of bias across all domains. Fifteen trials had a high risk of bias in at least one domain, mostly due to bias in measurement of the outcome. Interventions were assessed compared to standard care. Individual educational interventions may reduce short-term clinical signs (SCORAD) (mean difference (MD) -5.70, 95% confidence interval (CI) -9.39 to -2.01; 1 study, 30 participants; low‐certainty of evidence) but patient reported symptoms, quality of life, long-term atopic dermatitis control and psychological well-being were not reported. Group education interventions probably reduce clinical signs (SCORAD) both in the short term (MD: -9.66, 95% CI: -19.04 to -0.29; 3 studies, 731 participants; moderate-certainty of evidence) and the long term (MD -7.22, 95% CI -11.01 to -3.43; 3 studies, 1424 participants; moderate-certainty of evidence). Group education interventions reduce long-term patient reported symptoms (SMD -0.47 95% CI -0.60 to -0.33; 2 studies, 908 participants; moderate-certainty of evidence). Group education may slightly improve short-term quality of life (SMD -0.19, 95% CI -0.36 to -0.01; 4 studies, 746 participants; low certainty of evidence), but may make little or no difference to short-term psychological well-being (PSS) (MD -2.47, 95% CI -5.16 to 0.22; 1 study, 80 participants; low certainty of evidence). Long-term atopic dermatitis control was not reported. We are unable to comment on whether technology-mediated educational interventions could change short-term clinical signs (SCORAD) (1 study; 29 participants; very low certainty of evidence). Technology mediated education interventions may have little or no effect on short-term patient reported symptoms (POEM) (MD: -0.76, 95% CI: -1.84 to 0.33; 2 studies; 195 participants; low certainty of evidence) and probably have little or no effect on short-term quality of life (HRQoL) (MD: 0, 95% CI -0.03 to 0.03; 2 studies, 430 participants; moderate certainty of evidence). Technology-mediated education interventions probably slightly improve long-term atopic dermatitis control (RECAP) (MD -1.5, 95% CI -3.13 to 0.13; 1 study, 232 participants; moderate certainty), and may improve short-term psychological well-being (MD -1.78, 95% CI -2.13 to -1.43; 1 study, 24 participants; low certainty evidence). Habit reversal treatment may reduce short-term clinical signs (SCORAD) (MD: -6.57, 95% CI: -13.04 to -0.1; 1 study; 33 participants; low certainty of evidence) but we are uncertain about any effects on short-term quality of life (CDLQI) (1 study, 30 participants; very low certainty of evidence). Patient reported symptoms, long-term atopic dermatitis control and psychological well-being were not reported. We were uncertain whether arousal reduction therapy interventions could change short-term clinical signs (EASI) (1 study, 24 participants; very low certainty of evidence) or patient reported symptoms (VAS) (1 study; 18 participants; very low certainty of evidence). Arousal reduction therapy may improve short-term quality of life (DFI) (MD: -2.1, 95% CI: -4.41 to 0.21; 1 study, 91 participants; low certainty of evidence) and psychological well-being (PSS) (MD -1.2, 95% CI -3.38 to 0.98; 1 study, 91 participants; low certainty of evidence). Long-term atopic dermatitis control was not reported. No studies reported comparisons of standard care with self-help psychological interventions, psychological therapies or printed education. No adverse events were reported in any of the studies. Two health economic studies were identified. One found a 12-week technology-mediated educational support programme may be cost neutral. The other study found a nurse practitioner group education intervention may have lower costs than standard care provided by a dermatologist, with comparable effectiveness. Author's conclusions In person, individual education, as an adjunct to conventional topical therapy, may reduce short-term atopic dermatitis signs compared to standard care, but there is no information on atopic dermatitis symptoms, quality of life or long-term outcomes. Group education probably reduces atopic dermatitis signs and atopic dermatitis symptoms in the long-term and may also improve quality of life in the short-term. Favourable effects were also reported for technology-mediated education, habit reversal treatment and arousal reduction therapy. All favourable effects are of uncertain clinical significance, since they may not exceed the minimally clinically important difference (MCID) for the outcome measures used (MCID 8.7 points for SCORAD, 3.4 points for POEM). We found no trials of self-help psychological interventions, psychological therapies or printed education. Future trials should include more diverse populations, address shared priorities, evaluate long-term outcomes and ensure patients are involved in trial design