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Background: The main determinant of emollient effectiveness is whether it is used, which in turn is linked with user satisfaction., Objectives: To compare parental satisfaction with emollient type for the treatment of childhood eczema., Methods: Secondary analysis of data from the Best Emollients for Eczema (BEE) trial was undertaken. In total, 550 children aged between 6 months and 12 years were recruited from primary care in England and randomized to use a lotion, cream, gel or ointment as their main emollient for 16 weeks. At week, 16 parents were asked to complete an Emollient Satisfaction Questionnaire (ESQ). Completion rates and scores were compared, using χ2 test, t-test calculations and one-way Anova as appropriate., Results: Data on 378 participants (68.7% of those randomized) were analysed. Mean ESQ scores were gel 20.9 (SD 5.3), lotion 20.4 (SD 5.6), cream 18.8 (SD 6.3) and ointment 15.2 (SD 6.8) (P < 0.001). In pairwise comparisons, there was a statistically significant difference in mean ESQ scores between ointment and lotion (P < 0.001), ointment and cream (P < 0.001) and ointment and gel (P < 0.001) but not between lotion, cream and gel. Participants using lotions had highest overall satisfaction and were most likely to continue using their emollient. ESQ scores were correlated with reported emollient use and improvements in parent-reported eczema severity., Conclusions: Overall, lotions and gels were favoured over creams and ointments. Although satisfaction is determined by personal preference, these results will aid parents, clinicians and children to find the right emollient(s) for them., Competing Interests: Conflicts of interest M.J.R. devised the Emollient Satisfaction Questionnaire. The other authors declare no conflicts of interest., (© The Author(s) 2023. Published by Oxford University Press on behalf of British Association of Dermatologists.)

Background: It is unclear if ambient temperature changes affect eczema. It is also unclear if people with worse disease are more susceptible to weather-related flares, or specific types of emollient offer protection., Objectives: To investigate the effect of short-term temperature variations on eczema symptoms in children., Methods: Data from a UK cohort of 519 children with eczema were combined with data from the Hadley Centre's Integrated Surface Database. Hot and cold weeks were defined by average regional temperature > 75th or < 25th percentile, January 2018 to February 2020. Eczema flares were defined as ≥ 3-point change in Patient-Oriented Eczema Measure (POEM). Random-effects logistic regression models were used to estimate the odds ratios of flares in hot and cold weeks (reference group: temperate weeks)., Results: The baseline mean age was 4.9 years (SD 3.2) and the POEM score was 9.2 (SD 5.5). From the 519 participants, there were 6796 consecutively paired POEMs and 1082 flares. Seasonal variation in POEM scores was observed, suggesting symptoms worsening in winter and improving in summer. Odds ratios of flares were: 1.15 [95% confidence interval (CI) 0.96-1.39, P = 0.14] in cold weeks and 0.85 (95% CI 0.72-1.00, P = 0.05) in hot weeks. The likelihood ratio test showed no evidence of this differing by disease severity (P = 0.53) or emollient type used (P = 0.55)., Conclusions: Our findings are consistent with previous studies demonstrating either improvements in eczema symptoms or reduced flares in hot weather. Worse disease and different emollient types did not increase susceptibility or provide protection against temperature changes. Further work should investigate the role of sunlight, humidity, pollution and other environmental factors., Competing Interests: Conflicts of interest: The authors declare they have no conflicts of interest., (© The Author(s) 2023. Published by Oxford University Press on behalf of British Association of Dermatologists. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.)

Background: Emollients are a mainstay of treatment for dry skin conditions. In the UK, prescribers are usually expected to follow local National Health Service (NHS) formularies. A previous study in 2018 showed that the recommended emollients across England and Wales varied widely. Evidence has since emerged that bath additives provide no additional clinical benefit in eczema., Aim: To compare emollient formularies and guidelines in England., Methods: Clinical Commissioning Group (CCG) formularies and guidelines were identified in April-May 2021, compiled and then analysed descriptively., Results: In total, 105 CCGs, 72 emollient formularies and 47 emollient prescribing guidelines were identified. There were internal inconsistencies between formularies and their accompanying guidelines in 19% of cases. The majority (68%) of formularies/guidelines were organized using a ranking system. In total, 126 different leave-on emollients were named. Creams and ointments were universally available and were the most recommended first-line types. Cost was more likely than patient choice to be recommended as a criterion for selecting which emollient to prescribe. Aqueous cream was the leave-on emollient most commonly not recommended. Nearly three-quarters (74%) of formularies stated that bath additives should not be prescribed., Conclusion: All CCGs in England have an emollient formulary/guideline, but there is still great variability between them in their recommendations. Although the number of formularies/guidelines has reduced since 2017, there has been an increase in the total number of unique recommended leave-on emollients. Most CCGs are no longer recommending bath emollients for eczema., (© 2022 The Authors. Clinical and Experimental Dermatology published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists.)

Background: Emollients are used as maintenance therapy for all severities of eczema but there is a lack of head-to-head comparisons of effectiveness and acceptability., Aim: To determine the validity of a self-report questionnaire designed to assess user satisfaction with a given emollient and to report the findings., Methods: Data were analysed from the Choice of Moisturiser for Eczema Treatment trial, which compared four emollient types (Aveeno ® lotion, Diprobase ® cream, Doublebase ® gel and Hydromol ® ointment) in children aged < 5 years with clinically diagnosed eczema. An emollient satisfaction questionnaire was completed after 12 weeks. Responses for individual items were scored from 0 to 4. Total scores ranged from 0 to 28 (low to high satisfaction). Completion rates and distributions of responses for individual items and total scores, categorized by emollient type, were assessed, and two hypotheses were tested to determine the questionnaire's construct validity., Results: Data from 77.2% (152 of 197) of participants were analysed. One item was rejected because of a high rate (44.7%) of 'don't know' responses, leaving seven items with high completion rates (98.7%) and weak evidence of floor or ceiling effects. A positive association was observed between total score and overall emollient satisfaction (Spearman correlation 0.78; P < 0.001). Total scores were highest (mean ± SD 23.5 ± 3.9) in the lotion group and lowest (18.4 ± 4.6) in the ointment group., Conclusion: The emollient satisfaction questionnaire appears to have good validity. Further work is required to validate the questionnaire in other settings and to assess its reliability., (© 2022 The Authors. Clinical and Experimental Dermatology published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists.)

Background: Eczema (atopic dermatitis; AD) is a very common itchy skin condition affecting 1 in 5 children and up to 1 in 10 adults worldwide. The skin of eczema sufferers is prone to redness, irritation and dryness because it does not form an effective barrier, i.e. the ability of the skin to stop irritants, allergens and microorganisms getting into the body. Skin barrier dysfunction is a hallmark of AD. The regular and liberal (600 g/week for an adult) use of emollients is recommended for all patients with eczema), even between episodes of itching and redness, to soften and soothe the skin. In England alone, almost 9 million prescriptions for emollient creams were issued in 2018, at a cost of over £50 million. Despite this widespread use, relatively little is known about how commonly prescribed emollient creams affect the skin's barrier, and thus the role of moisturizers in AD development and progression remains unclear. We set out to compare three different types of emollient cream and a no-treatment control., Aim: To compare the barrier-strengthening properties of a new moisturizer containing urea and glycerol (urea-glycerol cream; UGC), with those of a glycerol-containing moisturizer (glycerol cream; GC), a simple paraffin cream (PC) with no humectant, and a no-treatment control (NTC)., Methods: This was an observer-blinded prospective Phase 2 within-subject multilateral single-centre randomized controlled trial in adults with AD (Clinical Trials #NCT03901144). The intervention involved 4 weeks of treatment, twice daily, with the three products applied to one of four areas on the forearms the (the fourth area was the untreated control, randomized allocation). Skin properties [dryness, transepidermal water loss (TEWL), hydration and natural moisturizing factor (NMF) levels] were assessed before, during and after treatment to see what happened to the skin's barrier. The primary outcome was skin sensitivity to the irritant sodium lauryl sulfate (SLS) after treatment. We performed tests on the skin before and after treatment to see what happened to the skin's barrier., Results: In total, 49 patients were randomized, completed treatment and included in the analysis. UGC significantly reduced the response to SLS as indicated by a reduction in TEWL compared with NTC (-9.0 g/m 2 /h; 95% CI -12.56 to -5.49), with PC (-9.0 g/m 2 /h; 95% CI -12.60 to -5.44) and with GC -4.2 g/m 2 /h; 95% CI 7.76 to -0.63). Skin moisturization improved at sites treated with UGC compared with NTC and PC, and this was accompanied by concordant changes in dryness and NMF levels. Subgroup analysis suggested FLG-dependent enhancement of treatment effects., Conclusion: The study showed that not all emollient creams for eczema are equal. The simple paraffin-based emollient, which represents the most widely prescribed type of emollient cream in England, had no effect on the skin's barrier and reduced the skin's NMF. UGC markedly improved the skin's barrier and protected against irritation. GC performed better than PC, but not as well as UGC. UGC strengthened the skin barrier through a mechanism involving increased NMF levels in the skin, and imparted protection from SLS-induced irritation. By helping correct a major pathophysiological process, UGC has the potential to improve the long-term control of AD. The results show that different emollient creams have different effects on our skin, and only certain types have the ability to improve the skin's barrier and protect against irritants that trigger eczema., (© 2022 The Authors. Clinical and Experimental Dermatology published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists.)

Background: Facial seborrhoeic dermatitis (FSD) is a chronic inflammatory skin disorder characterized by remission and exacerbation episodes. In most cases, FSD requires long-term treatment., Aim: To compare the efficacy and safety of pimecrolimus and sertaconazole in patients with FSD., Methods: In total, 60 patients with FSD were enrolled in this double-blind, active-controlled, randomized trial, and instructed to topically apply either pimecrolimus 1% cream (30 patients) or sertaconazole 2% cream (30 patients) twice daily for 4 weeks. Assessment of disease severity was performed using the Scoring Index (SI) at baseline, on Days 14 and 28, and at 4 weeks after treatment cessation. The levels of satisfaction from treatment and any adverse effects (AEs) were also assessed in both groups., Results: Although the severity of disease reduced upon treatment in both groups, application of pimecrolimus caused a significantly better improvement than sertaconazole on Days 14 and 28 (P < 0.01 and P < 0.001, respectively). The rate of relapse was significantly lower in the pimecrolimus compared with the sertaconazole group at 4 weeks after treatment cessation (P = 0.01). The highest level of satisfaction (46.7%) was observed on Day 28 in the pimecrolimus group. Both topical treatments had acceptable safety profiles; however, pimecrolimus 1% cream was significantly (P < 0.01) less irritating than sertaconazole 2% cream., Conclusion: Pimecrolimus is associated with faster response and fewer AEs than sertaconazole in patients with FSD., (© 2022 British Association of Dermatologists.)

This review forms part of a series of annual evidence updates on atopic eczema (AE), and provides a summary of key findings from systematic reviews (SRs) published or indexed in 2019 related to AE treatment. Several SRs assessed the efficacy of topical corticosteroids (TCS), topical calcineurin inhibitors, topical phosphodiesterase-4 inhibitors and topical Janus kinase/signal transducer and activator of transcription (JAK/STAT) pathway inhibitors. However, there is a lack of good-quality trials comparing topical treatment agents with TCS, which remain the standard of care for patients with AE. Most of the included trials lack meaningful comparisons as they used vehicle as a comparator. There is also lack of harmonization of outcome measures for AE across studies. Large, well-designed RCTs are needed to further determine whether any specific emollients offer superior benefit. There is evidence highlighting limited benefit of oral H1 antihistamines as 'add-on' therapy to topical treatment of eczema. Mycophenolate mofetil may have a role in patients with refractory AE. Among biologic therapies, most of the efficacy data relate to dupilumab. Furthermore, there is growing evidence for the efficacy and safety of systemic JAK/STAT pathway inhibitors, but the existing data are of low quality., (© 2021 The Authors. Clinical and Experimental Dermatology published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists.)

COVID-19 healthcare workers (HCWs) require frequent handwashing and use of personal protective equipment (PPE) to prevent infection. However, evidence is emerging that these practices are causing adverse effects on their skin integrity. A single-centre, cross-sectional study of HCWs from an Irish hospital was undertaken to evaluate the degree of COVID-19-related irritant contact dermatitis (ICD) between April and May 2020. Of 270 participants surveyed, 223 (82.6%) reported symptoms of ICD. The hands were the most commonly affected site (76.47%) and the most frequently reported symptom was dry skin (75.37%). Nearly all (268; 99.26%) HCWs had increased hand-washing frequency, but 122 (45.35%) did not use emollients. In the ICD group, 24.7% cited a history of dermatitis compared with 4.3% of unaffected staff (P < 0.001). The ICD group recorded PPE usage for an average of 3.15 h compared with the non-ICD group at 1.97 h (P = 0.21). Promoting awareness of COVID-19-related ICD is vital to highlight prevention and treatment for frontline staff., (© 2020 British Association of Dermatologists.)

While therapeutic approaches for psoriasis are widely available, preventive regimens are lacking. We aimed to determine whether improvements in epidermal function could prevent psoriasis relapse. Two self-controlled cohort studies were designed, enrolling two cohorts of patients with psoriasis (n = 30 and n = 60) to be treated topically with an in-house-prepared emollient or ATOPALM ® cream applied twice daily to one forearm for 20 and 30 days, respectively, while the same sites on the contralateral arm served as the untreated control. Epidermal function on both arms was assessed prior to and at the end of the trials. Delayed relapse on the treated arm was seen in 54.5% and 71% of patients in the first and second cohort, respectively. The time of psoriatic relapse correlated with the extent of abnormalities in baseline epidermal function. These results suggest that improvements in epidermal function with topical emollients can prevent/attenuate the development of psoriasis., (© 2019 British Association of Dermatologists.)

This review forms part of a series of annual updates that summarize the evidence base for atopic eczema (AE), providing a succinct guide for clinicians and patients. It provides a summary of key findings from 26 systematic reviews that were published during 2015, and focuses on the treatment and prevention of AE. For systematic reviews on the epidemiology and methodological issues, see Part 1 of this update. Topical corticosteroid withdrawal syndrome, 'steroid addiction', has been evaluated in a high-quality systematic review, which helps better define this entity and the risk factors for it. A Cochrane Review has not demonstrated any association between topical corticosteroid use in pregnancy and adverse outcomes, although very large quantities of potent/very potent topical corticosteroids may be associated with reduced birth weight. House dust mite avoidance strategies do not appear to prevent AE. Exposure to probiotics prenatally and in early infancy may help prevent AE, but there is no evidence that maternal diet or supplementation has a preventative effect., (© 2018 British Association of Dermatologists.)

Background: The choice of prescribed emollients is usually based on cost and patient preference. Differences in formulations can affect user acceptability., Aim: To compare the physical performance, user acceptability and various product design features of two emollient gels that are prescribed in the UK and alleged to be therapeutically interchangeable because their formulations are described as having the same contents of oily ingredients., Results: We found that here are in fact significant measurable differences between the structure and performance of the two formulations, which materially affect their user acceptability. These differences are attributed to the use of different types of gelling agents and other ingredients of differing grades/quality and concentrations, and probably due to the formulations being made by different manufacturing processes. We also identified other product design features that are important to user appeal, including the type of container in which the formulations are presented, the type of dispensing devices provided, and the nature and form of the supplied user instructions., Conclusion: Patients and prescribers should be aware that there can be important differences in performance and user appeal between emollients, even between products that, superficially, may appear to be very similar. These important performance aspects should be characterized for new emollient introductions to encourage better informed product selection., (© 2018 The Authors. Clinical and Experimental Dermatology published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists, North American Clinical Dermatologic Society and St Johns Dermatological Society.)

Background: Staphylococcus aureus (SA) colonization/infection is important in the pathophysiology of childhood atopic dermatitis (AD), but the role of Staphylococcus epidermidis (SE) is unknown., Aim: To evaluate if SE co-infects with SA and is associated with more severe disease., Methods: Associations between bacteriological culture results of skin swabs (taken from the most severely affected area and at the antecubital fossa) and SCORing Atopic Dermatitis (SCORAD) score, skin hydration, transepidermal water loss (TEWL) and quality of life (QoL) were evaluated., Results: In 100 consecutive patients with AD (aged 12.4 ± 4.8 years), SE was present in 28% and 32% of the swabs taken from the most severe area and the flexural area (antecubital fossa), respectively, whereas SA was present in 69% and 55%, respectively. Binomial logistic regression showed that SE was inversely associated with SA growth in the most severely affected skin site [adjusted odds ratio (aOR) = 0.42, 95% CI 0.22-0.81; P = 0.01], frequency of emollient usage (aOR = 0.50, 95% CI 0.29-0.87; P = 0.01) and frequency of oral antihistamine usage (aOR = 0.81, 95% CI 0.65-0.10, P < 0.05), but positively associated with objective SCORAD (aOR = 1.04, 95% CI 1.00-1.02; P < 0.05). SE in the antecubital fossa was not associated with SA growth, disease severity, QoL or any clinical parameters., Conclusions: SE may not be just a commensal bystander in the skin microbiota. The organism amensalistically displaces SA and is associated with more severe disease., (© 2016 British Association of Dermatologists.)

Background: Prurigo nodularis (PN), or nodular prurigo, is a chronic, debilitating, inflammatory skin disease. It can be very difficult to manage, and represents a challenge for the physician. Methotrexate (MTX) is a safe folic acid antagonist widely used in the management of inflammatory skin diseases such as psoriasis. Weekly administration of 7.5-20 mg methotrexate (low-dose methotrexate, LD-MTX) represents an attractive treatment option, and could therefore find a place in the management of PN., Aim: To evaluate the efficacy of LD-MTX as a treatment option for PN., Methods: Thirteen patients who had failed to respond to conventional therapies such as topical steroids, phototherapy and antipruritic agents were treated with LD-MTX. The mean age of the patients was 75.83. Objective symptoms (Prurigo Nodularis Area and Severity Index; PNASI) and subjective symptoms (Pruritus Numeric Rating Scale; PNRS) were recorded. Treatment consisted of one subcutaneous injection of MTX 7.5-20 mg once weekly for a minimum of 6 months. Adjuvant application of emollients and topical steroids was maintained where needed., Results: There was remission or marked improvement (decrease in both PNRS or PNASI of > 75%) in 10 cases, a trend to improvement in 2 cases and relapse in 1 case after treatment discontinuation., Conclusions: LD-MTX may allow improvement of PN in some patients, with long-lasting remission., (© 2014 British Association of Dermatologists.)

Emollients can perform an important role in the treatment of a number of dermatological conditions. Currently, the use of emollient therapy in the UK is supported only by limited guidelines and a best-practice statement, although guidelines do exist for specific conditions such as childhood eczema. To address this need, a group of clinical professionals covering acute community-care settings and medicines management met to review current data and practice. Their aim was to support other professionals in their approach to the use of emollient therapies in dry-skin conditions., (© The Author(s) CED © 2013 British Association of Dermatologists.)

This article discusses the effects of psoriasis, how to diagnose it confidently, and the options available for treatment, especially in primary care. We also suggest when referral to dermatology should be considered, and try to anticipate some frequently asked questions., (© 2012 The Author(s). Clinical and Experimental Dermatology © 2012 British Association of Dermatologists.)

This article discusses the effects of atopic eczema, how to diagnose it confidently, and the options available for treatment, especially in primary care. We also suggest when referral to dermatology departments in secondary care should be considered, and try to anticipate some frequently asked questions., (© 2012 The Author(s). Clinical and Experimental Dermatology © 2012 British Association of Dermatologists.)

The use of topical antiseptics in the treatment of atopic dermatitis (AD) has previously been explored. However, no triclosan-containing leave-on emollient has been evaluated previously, to our knowledge. The aims of this study were to assess the safety and efficacy of an emollient containing triclosan compared with the emollient alone (vehicle) for the treatment of AD. Eligible patients with mild to moderate AD were randomized to receive either the study cream or vehicle. All patients also received a low-potency corticosteroid cream to use during the treatment phase of the study if necessary. Patients were assessed for severity according to the SCORing Atopic Dermatitis (SCORAD) Index, amount of corticosteroid used, patient assessment of cream, and adverse events (AEs). In total, 60 patients received either the study cream or vehicle, and an intention-to-treat analysis was performed. At day 14, there was a significant decrease in SCORAD from baseline for the study cream compared with vehicle (P < 0.05). At day 27, although there was an improved mean reduction from baseline, this was no longer significant (P > 0.05). Only four patients had mild treatment-related AEs. The mean total amount of topical steroid applied by the patients using the study was significantly lower than that used by controls (P = 0.40). Triclosan-containing leave-on emollient was safe and highly acceptable to patients. However, the overall benefit on day 27 was not significant. Nevertheless, the amount of topical steroid used by patients was significantly less with the study cream than with the vehicle, thus further studies are needed to confirm its steroid-sparing effect.

Background: Atopic eczema (AE) is characterized by reduced skin hydration (SH) and impaired integrity of the skin. Proper emollient usage is an important facet of AE management and patients are encouraged to use emollients liberally., Aim: To evaluate whether the amount of emollient and skin cleanser used correlates with eczema severity, SH or transepidermal water loss (TEWL), and whether liberal usage alters disease severity, SH and TEWL., Methods: We studied SH and TEWL at three common measurement sites on the forearm (antecubital flexure, 20 mm below the antecubital flexure, mid-forearm) and determined the SCORing Atopic Dermatitis (SCORAD) score, Nottingham Eczema Severity Score (NESS), Children's Dermatology Life Quality Index (CDLQI) and the amount of emollient and cleanser usage over a 2-week period in consecutive new patients seen at the paediatric skin clinic of a teaching hospital., Results: In total, 48 subjects and 19 controls were recruited. Patients with AE had significantly higher TEWL and lower SH in the studied sites. Emollient and cleanser usage was significantly higher (P = 0.001 and P = 0.041, respectively) in patients with AE than in controls. The amount of emollient usage was correlated with NESS, SCORAD, CDLQI, TEWL and mid-forearm SH. No such correlation was found with cleanser usage. Regardless of SCORAD, prescribing 130 g/m(2)/week of emollient met the requirement of 95.8% of patients, and 73 g/m(2)/week met that of 85.4%; for the cleanser, prescribing 136 g/m(2)/week met the requirement of 91.7% of patients. Although skin dryness and SH were improved, there was no significant improvement in SCORAD or TEWL after 2 weeks. In terms of global acceptability of treatment, three-quarters of patients with AE and controls rated the combination of cream and cleanser as 'good' or 'very good'., Conclusions: Adequate amounts of emollient and bathing cleanser should be prescribed to patients with AE. These amounts can be conveniently estimated based on body surface area instead of the less readily available tools for disease severity, degree of SH or skin integrity. However, liberal usage of emollients and bathing cleanser alone does not seem to alter disease severity or TEWL within 2 weeks, implying that additional treatments are necessary to manage AE.

Atopic dermatitis (AD) is a common chronic skin disease, which mainly affects children. Xerosis is one of the most troublesome signs of the disease. The aim of this study was to evaluate the efficacy of liquid soap containing 12% ammonium lactate + 20% urea in patients with AD. In a randomized, double-blind study, 36 patients (both male and female patients; age range 3-40 years) with mild to moderate AD were enrolled. Patients were divided randomly into two groups, in a ratio of 2:1 (active:placebo). The prescribed soap was used on a daily basis during a shower for 3 weeks. All patients continued all other systemic or topical medication but avoided any other soap or emollients. After 3 weeks of treatment, efficacy was assessed both by clinician and patient. There were significant improvements in scaling (P < 0.0001), skin dryness (P < 0.0001) and redness (P = 0.03) as rated by the investigator, and subjective patient assessment of itch also improved (P < 0.001) in the study group compared with the control group. The liquid soap was found to be effective in patients with AD, as use of this soap in patients with stable mild to moderate AD improved the parameters studied.

The management of chronic hand eczema is often inadequate. There are currently no evidence-based guidelines specifically for the management of chronic hand eczema, and evidence for established treatments for hand eczema is not of sufficient quality to guide clinical practice. This consensus statement, based on a review of published data and clinical practice in both primary and secondary care, is intended to guide the management of chronic hand eczema. It describes the epidemiology and pathogenesis of hand eczema, its diagnosis and its effect on patients' quality of life. Management strategies include a skin education programme, lifestyle changes, and the use of emollients, barriers and soap substitutes. Topical drug therapy includes topical steroids and calcineurin inhibitors. Treatment with psoralen ultraviolet A and systemic therapies may then be appropriate, although there is no strong evidence of efficacy. Alitretinoin has been shown to be effective in a randomized controlled trial, and is currently the only treatment specifically licensed for the treatment of hand eczema. Recommendations for management are summarized in a treatment algorithm.

This review summarizes clinically important findings from 19 systematic reviews published between January 2006 and August 2007 on the topic of atopic eczema (AE). The evidence suggests that avoidance of allergenic foods during pregnancy or the use of hydrolyzed or soy formula milks does not prevent eczema. Delayed introduction of solids may decrease eczema risk. Asthma typically develops in around a third of children with eczema, and wheezing in early infancy is a predictor of risk. Established topical corticosteroids such as betamethasone should be used just once daily. Topical tacrolimus and pimecrolimus can be used for people who become dependent on topical corticosteroids, especially on sensitive sites such as the face. Wet wraps are useful in secondary care for inducing remission in a child, but they are not a treatment for mild eczema and they should not be used long term. Oral ciclosporin can be used for inducing a remission in severe eczema, and azathioprine can be considered for maintenance treatment. Narrowband ultraviolet (UV)B phototherapy can be used for chronic AE, and UVA1 may be useful for acute eczema. There is little convincing evidence of a clinical benefit with evening primrose oil for eczema, but there is some good new evidence that educational support to eczema families is beneficial. Future trials need to be larger, and include active comparators, patient-reported outcomes and longer-term aspects of disease control. They should be better reported, and registered on a public clinical trials register.

Background: Eczematous skin changes overlying port-wine stains have been reported to improve with pulsed-dye laser (PDL) treatment. However, PDL has not as yet been evaluated for the treatment of atopic dermatitis (AD; eczema)., Aim: To evaluate in a controlled trial the effects and safety of PDL treatment in children with AD who had chronic localized lesions., Methods: Twelve children with localized, chronic eczema were treated with PDL (595 nm), with untreated areas used as an intrapatient control. Treatment was given at baseline and patients were followed up at 2 and 6 weeks. Clinical outcome measures were localized Eczema Severity Score (ESS), a visual analogue scale (VAS) indicating eczema severity assessed by photographs, and adverse events., Results: After 2 and 6 weeks, a significant decrease in ESS was seen for the PDL-treated areas compared with the control areas (mean +/- SEM reduction in ESS 7.0 +/- 1.0 vs. 3.3 +/- 0.8 at 2 weeks, P = 0.003, and 7.8 +/- 1.4 vs. 4.9 +/- 1.3 at 6 weeks, P = 0.002). A significant difference in eczema severity assessed by VAS at 6 weeks was seen in favour of PDL (mean +/- SEM improvement 78% +/- 20% vs. 52% +/- 10%, P = 0.003). Treatment was well-tolerated., Conclusions: In this pilot study, PDL treatment was effective in treating small areas of chronic localized eczema. This may suggest that in AD dermal vasculature plays an important role or that PDL may have an effect on cutaneous immunological activation.

Erlotinib (Tarceva) is an epidermal growth factor receptor (EGFR) inhibitor, a member of a new group of molecular targeted drugs that combine high efficacy against tumours with less, often self-limiting, toxicity, compared with traditional chemotherapeutics. It is used for treatment of solid-organ tumours, especially as second- or third-line therapy for non-small-cell lung cancer. Dose-related cutaneous side-effects and diarrhoea may be a significant obstacle to treatment compliance. We present two cases with long-lasting acneiform eruptions, complicated by significant impetiginization, resulting in hospitalization in one case. The other patient suffered from sleep-disturbing, itching crusts on the scalp. As the use of EGFR inhibitors is increasing, clinicians should be aware of their side-effects. Early and timely dermatological intervention may diminish adverse events for patients treated with these agents and improve quality of life.

Many patients with rosacea are unable to tolerate extended treatment periods with topical agents because of the unusually high skin sensitivity that often accompanies rosacea. Kinetin (N(6)-furfuryladenine) is a plant cytokinin that reportedly helps restore skin barrier function and may be useful to ameliorate the signs and symptoms of rosacea. The purpose of this open-label study was to determine the tolerance and efficacy of twice-daily application of kinetin 0.1% lotion for improving the signs and symptoms of mild to moderate facial rosacea. Subjects applied kinetin 0.1% lotion twice daily to the face, with daily use of a sunscreen of sun protection factor 30. Subjects were evaluated at baseline and at 4-week intervals for 12 weeks to assess efficacy and tolerance. Results of this study suggest that kinetin 0.1% lotion is a well-tolerated moisturizing lotion option for subjects with mild to moderate inflammatory rosacea.

Data on dispensed prescriptions of topical corticosteroids and emollients were analysed in a population of 25 484 children aged

Lichen sclerosus (LS) is a chronic cutaneous disorder of uncertain aetiology seen predominantly in females. It is characterized by white atrophic macules and plaques with a predilection for involvement of the genitalia and perianal skin. Gender-identity disorder (transsexualism) is a descriptive term for individuals having the genetic, somatic and hormonal basis of one sex but who identify sexually with the opposite sex. Surgical gender reassignment is a fundamental step in the management of these complex patients and is driven by the individual's belief of being the opposite sex 'trapped' in the wrong body. We report a case of genital lichen sclerosus in hair-bearing skin originally from the scrotum, in an individual who had undergone male-to-female gender reassignment. To our knowledge, no similar cases have been reported to date.

Transepidermal water loss (TEWL) in psoriatic skin lesions seems to be related to the severity of the psoriasis, and the electrical capacitance and conductance of the skin are indicators of the hydration level of the stratum corneum. We compared the characteristics of these electrical measurements, in assessing the persistent effect of a moisturizing cream on skin hydration and barrier function in psoriasis patients. Seventeen Korean psoriasis patients were recruited. Their right leg was treated with the moisturizer twice daily for 6 weeks, while their left leg was used as the control site. For each patient, one psoriatic plaque on each leg was selected as the involved psoriatic lesion. Uninvolved psoriatic skin was regarded as the apparently healthy looking skin 4-5 cm away from the periphery of the psoriatic lesion. The TEWL, electrical capacitance and conductance were measured, in order to evaluate the barrier function and hydration level of the stratum corneum. The clinical and biophysical data for each patient were recorded at the start of the study and after 2, 4 and 6 weeks. The degree of skin dryness at the applied area improved progressively. The electrical capacitance at the treated psoriatic lesion increased significantly after 2 weeks, and this improvement was maintained during the entire study period. However, no noticeable change was observed in the electrical conductance. The TEWL showed an inverse pattern to that of the skin capacitance, decreasing during the study period. The skin capacitance and TEWL exhibited good correlation with the visual assessment of skin dryness, but the skin conductance did not. Our data suggest that electrical capacitance and TEWL may be useful in the evaluation of the effect of a moisturizer on the hydration status and barrier function of psoriatic skin.

Multiple minute digitate hyperkeratosis (MMDH) is a skin disease of unknown aetiology characterized clinically by multiple minute asymptomatic keratotic lesions with spiky horny projections. The disorder has been classified into early (congenital) and late (acquired) onset forms, the latter occurring as a presenting sign of concomitant inflammatory, metabolic or malignant disease. Here we report two cases of late onset MMDH without any associated pathology. These cases emphasize that some cases of late-onset MMDH may be idiopathic.

Eighteen black South African patients with pityriasis rubra pilaris were prospectively studied, nine adults and nine children; patients with the classical types (namely I and III) constituted 75% of the group. Follicular involvement was very prominent, especially in the children with type III, but otherwise the clinical and histological findings did not differ from those reported in white patients. This is the first series of black African patients with this condition to be reported.

Clinical grading of dry skin syndromes (xerosis) is beset by many variables which limit its reliability. Removing scales onto adhesive coated discs (D-Squames) has provided a means for objective measurement of xerotic states. Using image analysis we have modified the basic procedure to assure greater accuracy and reproducibility. The distribution of grey values on the discs was determined, from which a single value of the degree of scaling was calculated. We term this the scaling index. To induce xerosis, the lower legs of 22 women, aged 26-64, were washed daily for 10 days with soap. After washing, one side received a moisturizing lotion, the other served as an untreated control. At specified intervals, scaling was graded clinically, electrical conductance was measured and D-Squames were obtained. On the moisturizer-treated legs there was a significant decrease in dryness grades and scaling indices at all time points. Conductance was significantly increased on days 8 and 11. The untreated washed legs showed no changes in clinical grades, although conductance significantly decreased and the scaling indices increased in the last stage of the study. D-Squame analysis unequivocally revealed the beneficial effect of a moisturizer on soap-induced xerosis and the expected increase in scaliness without treatment.

A patient is described who presented with an eruption of tiny follicular keratotic papules on the limbs and the trunk accompanied by profuse hair loss. Histologically, a diagnosis of keratosis pilaris was made. The eruption cleared spontaneously in 3 months with complete regrowth of hair. Neither atrophy nor scarring remained. This appears to be the first reported case of keratosis pilaris decalvans non-atrophicans.