Editorial: Wrapping up the problem

Journal of Dermatological Treatment ISSN: 0954-6634 (Print) 1471-1753 (Online) Journal homepage: https://www.tandfonline.com/loi/ijdt20 Editorial: Wrapping up the problem Richard J. Motley To cite this article: Richard J. Motley (1994) Editorial: Wrapping up the problem, Journal of Dermatological Treatment, 5:2, 57-58, DOI: 10.3109/09546639409084529 To link to this article: https://doi.org/10.3109/09546639409084529 Published online: 12 Jul 2009. Submit your article to this journal Article views: 30 View related articles Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=ijdt20 zyxwvu zyxwvutsrqp zyxwvutsrqp zyxwvutsrq zyxwvutsrqp zyxwv Journal of Dermarological Treatment (1994), 5: 51 - 58 Editorial 0 Journal of Dermatological Treatment, 1994 Wrapping up the problem There is nothing new about applying dressings to inflamed skin. If the skin is widely affected by eczema, it makes sense to protect it from scratching and soothe it with a cool, moist dressing. Tar preparations and occlusion were frequently used before the advent of topical steroids; the introduction of this powerful therapy reduced the emphasis on the use of dressings, which have generally been confined to inpatient use since. The concept of ‘wet-wrap’ dressings revisits an old idea; Mallon et a1 (page 97) claim that this dressing technique is not only comfortable and well tolerated, but can be used effectively in an outpatient setting. The clinical descriptions of this technique are helpful - but only as a starting point. Advocates of wet-wraps should demonstrate their effectiveness and safety with the same degree of intellectual rigour required when a new drug is introduced. What are the relative contributions of occlusion, moisture and steroid to the efficacy of the technique? How much topical steroid is absorbed under these conditions? What are the medium- and long-term follow-up data? What are the results of controlled trials comparing this technique to other methods of applying topical steroids? We await the answers. Thinking out eczema Atopic eczema can be a terribly destructive disease. The persistent itch with its consequent damaging scratch response causes great discomfort and sleeplessness, which often spreads to the entire family. How can we calm this unpleasant sensation short of shutting off the eczema by using the ‘big guns’ of systemic corticosteroids or cyclosporin and risking serious side-effects? Regrettably, simpler pharmacological manoeuvres using H, antihistamines do little more than tranquillize, and psychotropic drugs themselves do not seem to help. It is no wonder, therefore, that attempts have been made to alter behaviour using psychological techniques. The paper by Derrick and colleagues (page 83) describes what appears to be a harmless, though perhaps time-consuming, way of using the child’s own imagination to calm their itch. Some improvement was found, but this did not reach statistical significance. Perhaps this was because the methods of clinical assessment used were not sufficiently sensitive, or because the technique only produced a minor degree of improvement. In any event, and regardless of the disappointing result, the authors are to be applauded for testing a treatment that is intrinsically difficult to submit to trial for a condition that desperately needs help. Innovations We try to provide a comprehensive collection of original articles, reviews and opinions focusing on dermatological treatments. At the same time, we hope to reflect what is happening right now in the clinic or office and attempt to respond to our readers’ wishes and preferences. For these reasons we have started three new sections. Two of these are included in this edition and the third will appear in the next. Laws, patents, licenses, take overs in the pharmaceutical industry and the status of new drugs are amongst the topics to be covered in our new editorial section called ‘Regulatory Affairs’. Dr Jim Murray has had extensive experience in this area and we are sure that you will find this addition to the editorial comments both informative and entertaining. How much do we miss by not being able to speak Japanese, Spanish, German or French? Are our patients missing out on effective treatments publicized in a different language? To try to prevent this happening we have initiated regular reviews of papers not published in English. We hope that these foreign literature reviews will help to broaden our knowledge base. The third innovation reflects the importance of training in developing skills in treatment and gives a voice to trainees who wish to comment on the training for treatment. Dr Alex Anstey, who has just completed training and is a newly appointed consultant, will supervise this section called ‘Trainees’ Forum’, the first of which will be in the next edition. New horizons for cyclosporin? Cyclosporin has important and unique biological effects on the body’s immune response. First utilized to block the immunologically-mediated rejection of transplanted organs - kidneys in particular, cyclosporin has also now found several uses in dermatology. It is now licensed in the UK for the treatment of severe, intractable psoriasis as well as generalized, stubborn atopic dermatitis and has provided almost miraculous relief for some patients with these life-destroying dermatoses. Cyclosporin has also been reported to improve patients with autoimmune diseases, but its place in the treatment of these disorders is currently uncertain. This edition of the JDTcarries an important paper documenting the use of the drug in patients with recurrent allergic vasculitis- Stratigos and his colleagues from Athens (page 93) treated 13 patients with this disorder with either cyclosporin alone or in combination with prednisolone and obtained good results in all but 58 zyxwvutsrqponm zyxwvutsrqpon EDITORIAL three, who had to discontinue because.of a more than 3% rise in serum creatinine. This renotoxic side-effect is a major drawback to the use of cyclosporin and has encouraged attempts to formulate topical preparations, which clearly would be much less of a threat to the kidneys. Unfortunately the results have been inconsistent and variable, probably because of the difficulty in making cyclosporin cross the stratum corneum barrier. Nelson and co-workers from Ann Arbor, Michigan (page 77), hoped that a liposomal vehicle would overcome this hurdle, but in a carefully performed study were disappointed to find that their cyclosporin preparation did not produce any increase in hair growth in patients with alopecia areata compared to the liposomal vehicle alone. Will other formulations be better? Perhaps more is needed than a temporary block in cytokine synthesis by lymphocytes at the site of the disease. Any suggestions from our readers? zyxwvu zyxwvuts zyxw zy zyxwv Guest editorial: Sepsis and skin surgery The skin forms a natural barrier to infection but may be colonized by pathogenic bacteria - in particular Staphylococcus aureus or Sfreptococcuspyogenes - organisms found in the majority of wound infections from outpatient surgeries.’ It has long been recognized that most wound infections are caused by organisms resident on the patient’s own skin. In routine, elective, surgery the rate of post-operative wound infection should be low, 1.5% or less, and although most dermatologists perform cutaneous surgical procedures in an outpatient setting without the rigorously controlled environment of a surgical operating room, the incidence of wound infection remains low.” Pre-operative antisepsisand good surgical technique are important factors determining wound infection rates. Prophylactic antibiotics tend to be overused but may be indicated for wounds in sites liable to contamination, such as the oral cavity, axilla, perineum and ears, where the risk of contamination is high, or where there is reduced host immunity through age, debility or disease.* Antibiotics should be effective against the common pathogens and should be given two hours before surgery.’ The incidence of bacteraemia during cutaneous surgery is low and only patients with prosthetic heart valves need antibiotic prophylaxisagainst endocarditis.s.6Current recommendationsare for parenteral vancomycin or teicoplanin 2 hours preand 12 hours post-operation in patients with young prosthetic valves (<60 days) and a first generation cephalosporin in patients with older valves. In this issue of the JDT, Terui and Tagami (page 59) describe a new oral cephalosporin, cefpodoxime proxetil, with broad-spectrum activity against a wide range of bacteria isolated from cutaneous infections. Not all such isolates are pathogenic in the skin, however, and further controlled studies are necessary to evaluate the potential therapeutic benefits of this new antibiotic in cutaneous infection. One possible role for its broad-spectrum activity is in prophylaxis against prosthetic valve endocarditis. Richard J Motley References 1. Takegami KT, Siegle RJ, Ayers LW, Microbiologiccountsduring outpatientoffice-based cutaneous surgery. J Am Acad Dermatol 11990) 2 3 1149-52. 2. Seb&n JE, Survey of sterile technique used by dermatologic surgeons. J Am Acad Dermatol(l988) 1 8 1107- 13. 3. Freeman WE, Chalker DK, Graham Smith Jr J, Use of gloves among dermatologists. J Am Acad Dermatol(l987) 17: 320-3. 4. Classen DC, Evans RS, Pestotnik SL et al, The timing of prophylactic administration of antibiotics and the risk of surgical wound infection. N Engl J Med (1992) 326: 281 -6. 5. Halpern AC, Leyden JJ, Dzubow LM et al, The incidence of bacteraemia in skin surgery of the head and neck. J Am Acad Dermarol(l988) 1 9 112-16. 6. Sabetta JB, Zitelli JA, The incidence of bacteraemia during skin surgery. Arch Dermatol(l987) 1U: 213-15.