Established corticosteroid creams should be applied only once daily in patients with atopic eczema

Atopic eczema affects many adults and up to 20% of children,1 with health costs comparable to diabetes2 and asthma.3 One community survey of 1760 young children in the United Kingdom found that 84% had mild eczema, 14% moderate, and 2% severe eczema.4 Topical corticosteroids are a mainstay of treatment for inflammatory episodes.5 Most long established topical corticosteroids such as betamethasone valerate or hydrocortisone are applied at least twice daily, but three newer preparations (mometasone, fluticasone, and methylprednisolone) have been developed for once daily application. Here, I propose that established preparations need be applied only once daily

Prevention of Atopic Dermatitis

Despite advances in atopic dermatitis (AD) treatments, research into AD prevention has been slow. Systematic reviews of prevention strategies promoting exclusive and prolonged breastfeeding, or interventions that reduce ingested or airborne allergens during pregnancy and after birth have generally not shown convincing benefit. Maternal/infant supplements such as Vitamin D have also not shown any benefit with the possible exception of omega-3 fatty acids. Systematic reviews suggest that probiotics could reduce AD incidence by around 20%, although the studies are quite variable and might benefit from individual patient data meta-analysis. Skin barrier enhancement from birth to prevent AD and food allergy has received recent interest, and results from national trials are awaited. It is possible that trying to influence major immunological changes that characterise AD at birth through infant-directed interventions may be too late, and more attention might be directed at fetal programming in utero

On the definition of dermatological disease. Part 1: conceptual frameworks

Little attention is paid to disease definition in dermatology and how such definitions come about, yet defining a disease is a fundamental step upon which all subsequent clinical management and prognostic judgements depend. Developing diagnostic criteria is also a critically important step for research purposes so that studies referring to groups of people can be compared in a meaningful way. This short review introduces the concepts of regressive and progressive nosology, and how definitions of a dermatological disease can evolve in a useful way as knowledge about that disease increases. It also highlights the dangers of panchrestons – names that try to explain all yet end up explaining very little. It also considers approaches to disease definition, such as whether a binary yes/no or continuous approach is more appropriate. Conceptual frameworks including essentialistic vs. nominalistic approaches using the biomedical or biopsychosocial perspectives are articulated. The review then illustrates hazards of underdiagnosis and overdiagnosis, and introduces the notion of ‘disease mongering’ – the selling of disease in order to promote the use of medicines. The review concludes with a reaffirmation of the importance of defining dermatological disease, and why any new diagnostic criteria must be shown to increase predictive ability before they are assimilated into clinical practice and research

Problems in the reporting of acne clinical trials: a spot check from the 2009 Annual Evidence Update on Acne Vulgaris

In the course of producing the 2009 NHS Evidence - skin disorders Annual Evidence Update on Acne Vulgaris, 25 randomised controlled trials were examined. From these, at least 12 potentially serious problems of trial reporting were identified. Several trials concluded no effect of a treatment yet they were insufficiently powered to exclude potentially useful benefits. There were examples of duplicate publication and "salami publication", as well as two trials being combined and reported as one. In some cases, an incorrect "within-groups" statistical comparison was made and one trial report omitted original efficacy data and included only P values. Both of the non-inferiority studies examined failed to pre-specify a non-inferiority margin. Trials reported as "double-blind" compared treatments that were dissimilar in appearance or had differing adverse effect profiles. In one case an intention-to-treat analysis was not performed and there was a failure to account for all of the randomized participants. Trial results were made to sound more impressive by selective outcome reporting, emphasizing the statistical significance of treatment effects that were clinically insignificant, and by the use of larger-sounding odds ratios rather than rate ratios for common events. Most of the reporting problems could have been avoided by use of the CONSORT guidelines and prospective trial registration on a public clinical trials database

Introducing the National Library for Health Skin Conditions Specialist Library

Background: This paper introduces the new National Library for Health Skin Conditions Specialist Library http://www.library.nhs.uk/skin. Description: The aims, scope and audience of the new NLH Skin Conditions Specialist Library, and the composition and functions of its core Project Team, Editorial Team and Stakeholders Group are described. The Library's collection building strategy, resource and information types, editorial policies, quality checklist, taxonomy for content indexing, organisation and navigation, and user interface are all presented in detail. The paper also explores the expected impact and utility of the new Library, as well as some possible future directions for further development. Conclusion: The Skin Conditions Specialist Library is not just another new Web site that dermatologists might want to add to their Internet favourites then forget about it. It is intended to be a practical, "one-stop shop" dermatology information service for everyday practical use, offering high quality, up-to-date resources, and adopting robust evidence-based and knowledge management approaches

Evidence-based management of eczema: five things that should be done more and five things that should be dropped

Purpose of review We provide readers with an evidence-informed opinion on current treatments for eczema (atopic dermatitis) with the intention of improving patient care. We suggest five treatment aspects that should be promoted and five that should be demoted. Evidence sources include key randomized controlled trials and systematic reviews.Recent findings Under-treatment of eczema can be countered by more aggressive use of topical therapies including the ‘get control then keep control’ regimen, and systemics for severe disease, supplemented with good patient education. Topical corticosteroids should be used once daily rather than twice daily. Topical calcineurin inhibitors are useful for sensitive sites. There is little evidence to support the continued use of oral antihistamines, oral or topical antistaphylococcal treatments for infected eczema or probiotics for treating eczema. Nonpharmacological treatments including silk clothing, ion-exchange water softeners and emollient bath additives have not been shown to benefit eczema patients. Despite promising pilot studies, large trials suggest that emollients from birth do not prevent eczema and may result in harms such as increased skin infections and food allergy.Summary New evidence-based insights on existing and newer treatments allow clinicians the opportunity to change their practice in a way that enhances patients’ quality of life

Development of a critical appraisal tool to assess the quality of cross-sectional studies (AXIS)

Objectives: The aim of this study was to develop a critical appraisal (CA) tool that addressed study design and reporting quality as well as the risk of bias in cross-sectional studies (CSSs). In addition, the aim was to produce a help document to guide the non-expert user through the tool. Design: An initial scoping review of the published literature and key epidemiological texts was undertaken prior to the formation of a Delphi panel to establish key components for a CA tool for CSSs. A consensus of 80% was required from the Delphi panel for any component to be included in the final tool. Results: An initial list of 39 components was identified through examination of existing resources. An international Delphi panel of 18 medical and veterinary experts was established. After 3 rounds of the Delphi process, the Appraisal tool for Cross-Sectional Studies (AXIS tool) was developed by consensus and consisted of 20 components. A detailed explanatory document was also developed with the tool, giving expanded explanation of each question and providing simple interpretations and examples of the epidemiological concepts being examined in each question to aid non-expert users. Conclusions: CA of the literature is a vital step in evidence synthesis and therefore evidence-based decision-making in a number of different disciplines. The AXIS tool is therefore unique and was developed in a way that it can be used across disciplines to aid the inclusion of CSSs in systematic reviews, guidelines and clinical decision-making

Two-by-two factorial randomised study within a trial (SWAT) to evaluate strategies for follow-up in a randomised prevention trial

BackgroundFailure to collect outcome data in randomised trials can result in bias and loss of statistical power. Further evaluations of strategies to increase retention are required. We assessed the effectiveness of two strategies for retention in a randomised prevention trial using a two-by-two factorial randomised study within a trial (SWAT).MethodsParents of babies included in the host trial were randomised to (1) short message service (SMS) notification prior to sending questionnaires at 3, 6, 12 and 18 months versus no SMS notification and (2) a £10 voucher sent with the invitation letter for the primary follow-up visit at 24 months or given at the visit. The two co-primary outcomes were collection of host trial (1) questionnaire data at interim follow-up times and (2) primary outcome at 24 months during a home/clinic visit with a research nurse.ResultsBetween November 2014 and November 2016, 1394 participants were randomised: 350 to no SMS + voucher at visit, 345 to SMS + voucher at visit, 352 to no SMS + voucher before visit and 347 to SMS + voucher before visit. Overall questionnaire data was collected at interim follow-up times for 75% in both the group allocated to the prior SMS notification and the group allocated to no SMS notification (odds ratio (OR) SMS versus none 1.02, 95% CI 0.83 to 1.25). Host trial primary outcome data was collected at a visit for 557 (80%) allocated to the voucher before the visit in the invitation letter and for 566 (81%) whose parents were allocated to receive the voucher at the visit (OR before versus at visit 0.89, 95% CI 0.69 to 1.17).ConclusionThere was no evidence of a difference in retention according to SMS notification or voucher timing. Future synthesis of SWAT results is required to be able to detect small but important incremental effects of retention strategies

Conflicts of interest in dermatology

Conflicts of interest exist in dermatology when professional judgement concerning a primary interest, such as research validity, may be influenced by a secondary interest, such as financial gain from a for-profit organization. Conflict of interest is a condition and not a behaviour, although there is clear evidence that gifts influence behaviour. Little has been written about conflicts of interest in dermatology. This series of papers raises awareness of the subject by exploring it in greater depth from the perspective of a dermatology researcher, an industry researcher, a dermatology journal editor, a health services researcher and a patient representative. Collectively, they illustrate the many ways in which conflicts can pervade the world of dermatology publications and patient support group activities

Long-term management of moderate-to-severe atopic dermatitis with dupilumab and concomitant topical corticosteroids (LIBERTY AD CHRONOS): a critical appraisal

Aim Blauvelt et al. (The Lancet 2017; 389: 2287-303) aimed to compare the long-term efficacy and safety of dupilumab with medium-potency topical corticosteroids (TCS) versus placebo with TCS in adults with moderate-to-severe atopic dermatitis (AD). Setting and design This multicentre randomised, double-blinded, placebo-controlled trial was conducted in hospitals, clinics and academic institutions across 161 sites in 14 countries. Study exposure Adults with moderate-to-severe AD were randomly assigned (3:1:3) to receive subcutaneous dupilumab 300mg once weekly (qw) plus TCS, dupilumab 300mg every 2 weeks (q2w) plus TCS, or placebo plus TCS until week-52. Primary outcome measures Co-primary efficacy endpoints were patients (%) achieving Investigator's Global Assessment (IGA) 0/1 and 2-points or higher improvement from baseline, and Eczema Area and Severity Index 75% improvement from baseline (EASI-75) at week-16. Results 740 patients were included in the trial: 319 were randomly assigned to dupilumab qw, 106 to dupilumab q2w and 315 to the placebo arm. At week-16, more patients in the dupilumab groups achieved the co-primary endpoints: IGA 0/1 (39% [125 patients] qw dosing, 39% [41 patients] q2w dosing vs 12% [39 patients] receiving placebo; p<0.0001) and EASI-75 (64% [204] and 69% [73] vs 23% [73]; p<0.0001). Whilst no new safety signals were identified, adverse effects (AEs) were noted in 261 (83%) in those receiving dupilumab qw plus TCS, 97 (88%) dupilumab q2w plus TCS and 266 (84%) for placebo plus TCS. Rates of conjunctivitis, injection site reactions and local herpes simplex infections were higher in the dupilumab groups compared with placebo. Conclusions Blauvelt et al. concluded that dupilumab treatment added to TCS improved AD up to week-52 compared with TCS alone, and also demonstrated acceptable safety