2022+意大利共识：湿疹的局部非药物治疗.pdf

402 ItalIan Journal of Dermatology anD Venereology october 2022 GU I D ELI N EStopical non-pharmacological treatment of eczema:an Italian consensusfabrizio guarnerI 1*,anna BellonI fortIna 2,monica CoraZZa 3,antonio CrIStauDo 4,Caterina fotI 5,aurora ParoDI 6,Paolo PIgatto 7,luca StIngenI 8,ornella De PIt 91unit of Dermatology,Department of Clinical and experimental medicine,university of messina,messina,Italy;2unit of Dermatology,Department of medicine DImeD,university of Padua,Padua,Italy;3Section of Dermatology and Infectious Diseases,Department of medical Sciences,university of ferrara,ferrara,Italy;4San gallicano Dermatological Institute IrCCS,roma,Italy;5Department of Biomedical Sciences and Human oncology,aldo moro university of Bari,Bari,Italy;6Section of Dermatology,Department of Health Sciences,university of genoa,genoa,Italy;7unit of Dermatology,Department of Surgical and odontoiatric Biomedical Sciences,galeazzi IrCCS orthopedic Institute,milan,Italy;8Section of Dermatology,Department of medicine and Surgery,university of Perugia,Perugia,Italy;9Unit of Clinical Pathology,Inflammatory and Autoimmune Skin Diseases,Cristo Re Hospital,Rome,Italy*Corresponding author:fabrizio guarneri,unit of Dermatology,Department of Clinical and experimental medicine,university of messina,viale annun-ziata residence dei fiori villa 7,98168 messina,Italy.e-mail:f.guarneritiscali.ita BStraCtEczematous diseases(contact dermatitis,atopic dermatitis,hand eczema)are among the most frequent findings in dermatological clinical practice.A large body of evidence exists on structural and functional skin barrier damage in eczematous diseases,and on the importance of interventions aimed to repair such damage.While there is substantial agreement on pharmacological treatment,more sparse data are available on role,indications and usefulness of topical non-pharmacological treatments,despite significant research and progress in the composition and technology of emollients,cleansers and barrier creams significantly changed and expanded the functional activities of these products.This often leads to inadequate prescription and/or use,which increase individual and social costs of the disease and make the products useless or,in some cases,even counterproductive.this consensus document,discussed and compiled in a series of meetings by a group of Italian dermatologists experienced in the field of eczematous diseases,summarizes epidemiology and clinical features of the nosological entities of the“eczema fam-ily”,illustrates the chemical/biochemical structure of emollients,cleansers and barrier creams,and aims to help physicians to exploit the full potential of available products,by providing a detailed but practical guide on characteristics,indications and correct use of non-pharmacological treatments currently available for eczematous diseases.(Cite this article as:guarneri f,Belloni fortina a,Corazza m,Cristaudo a,foti C,Parodi a,et al.topical non-pharmacological treatment of eczema:an Italian consensus.Ital J Dermatol Venereol 2022;157:402-13.DoI:10.23736/S2784-8671.22.07283-8)Key words:eczema;Dermatitis,irritant;Dermatitis,allergic contact;Dermatitis,atopic;Hand;emollients.Italian Journal of Dermatology and Venereology 2022 october;157(5):402-13DoI:10.23736/S2784-8671.22.07283-8 2022 eDIZIonI mInerVa meDICaonline version at https:/www.minervamedica.itthe“eczema family”includes some very common,non-infectious inflammatory diseases,namely contact dermatitis(CD),atopic dermatitis(aD)and hand eczema(He).the acute phase of these diseases is mainly charac-terized by erythema,edema,vesicles,exudation and crusts,while chronic lesions show reactive epidermal changes such as lichenification and desquamation.1-5 alterations of the skin barrier function,acquired and/or constitutional,are always present.2multiple mechanisms may concur in the pathogenesis of eczema,and therefore mixed clinical pictures,with characteristics of different eczematous diseases,are fre-quent in real life conditions.5 Particularly when chronic and/or localized to sensitive areas,these diseases have high individual and social costs,direct and indirect,may significantly impair the quality of life and,when hands are involved,negatively affect the ability to work and/or per-form daily activities.4,6,7avoidance of irritants and/or contact allergens is obvi-ously the best option to obtain complete and durable reso-lution of eczema in the case of CD and is helpful also in the case of aD,but it is often neither easy nor immediate COPYRIGHT 2022 EDIZIONI MINERVA MEDICAThis document is protected by international copyright laws.No additional reproduction is authorized.It is permitted for personal use to download and save only one file and print only one copy of this Article.It is not permitted to make additional copies(either sporadically or systematically,either printed or electronic)of the Article for any purpose.It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems,electronic mailing or any other means which may allow access to the Article.The use of all or any part of the Article for any Commercial Use is not permitted.The creation of derivative works from the Article is not permitted.The production of reprints for personal or commercial use is not permitted.It is not permitted to remove,cover,overlay,obscure,block,or change any copyright notices or terms of use which the Publisher may post on the Article.It is not permitted to frame or use framing techniques to enclose any trademark,logo,or other proprietary information of the Publisher.non-PHarmaCologICal treatment of eCZema guarnerIVol.157-no.5 ItalIan Journal of Dermatology anD Venereology 403general population was affected;the prevalence was high-er in adults than in children(21.4%vs.16.5%),in women than in men(27.9%vs.13.2%),and in girls than in boys(19.0%vs.12.4%).14the trend of increasing prevalence from childhood to adulthood is consistent with the increase of cumulative allergenic stimulation and reactivity of the immune sys-tem.5 Similarly to allergies and autoimmune diseases,15-17 aCD is more frequent among females.no geographic dif-ferences were found between europe and america,while no studies were conducted in africa.14 for which concerns asia,epidemiological studies were carried out only in China,and showed a prevalence similar to the european one.14,18,19 Interestingly,data are not consistent with the global Burden of Diseases data on atopic dermatitis,20-22 a pathological condition in which the skin barrier is im-paired and the immune system may over-react to environ-mental allergens.a new element in the epidemiology of CD has arisen during the CoVID-19 pandemics.In this period,the pro-longed and large-scale use of masks and gloves has caused a significant increase of ACD and ICD,because of skin barrier alterations and allergic sensitization caused by the components of such personal protective equipment.23-28moreover,use of hand sanitizers(alcohol-or not alco-hol-based)and frequent handwashing,recommended for the prevention of CoVID-19,have dramatically increased hand ICD.No extensive estimates of the modification of the frequency of ICD in the general population are current-ly available,but dermatological societies produced alerts and position papers suggesting to limit hand exposure.29Atopic dermatitisepidemiological data are widely variable between studies,depending not only on the population considered,but also on discrepancies between methods used,disease defini-tions and diagnostic criteria,particularly for which con-cerns adult aD.30aD is prevalently a childhood disease,although adults can also be affected.In about 80%of cases,it occurs in the first years of life,and in 60%of them undergoes spontane-ous remission in adolescence.30 the majority of adult aD patients are those who do not undergo such remission,but adult-onset aD represents 26.1%of all cases.31overall,females are affected more frequently than males.30 Studies performed in the last 20 years report a point prevalence in children up to 18.2%;one-year preva-lence is between 0.96%and 22.6%,one-year incidence between 10.2 and 95.6 per 1000 person years.30 In adults,to achieve,and medical treatment is required to reduce in-flammation,alleviate the suffering of patients and restore barrier function as much as possible.8 While there is sub-stantial agreement on pharmacological treatment,more sparse data are available on role,indications and useful-ness of topical non-pharmacological treatments,9 despite significant research and progress in the composition and technology of emollients,cleansers and barrier creams.The lack of consensus in this field too often prevents pa-tients and physicians from fully exploiting the potential of available products,and in some cases leads to inadequate advice,resulting in a decrease of efficacy of pharmaco-logical treatment,or even further physical/functional dam-age to the skin barrier,not to mention the unfruitful costs and the loss of confidence in topical non-pharmacological treatments.this consensus document,which was discussed and compiled in a series of meetings by a group of Italian der-matologists experienced in the field of eczematous dis-eases,represents an attempt to fill this void in the current scientific literature,providing physicians with a practical guide on characteristics,indications and correct use of topical non-pharmacological treatments currently avail-able for eczema.EpidemiologyContact dermatitisDespite CD is a common condition,several studies fo-cused their attention only on its frequency in special work-ers(e.g.healthcare workers10 or hairdressers11).Indeed,assessment of the frequency of CD in the gen-eral population is particularly tricky,not only because of the possible underreporting of less severe cases,but also because this condition may co-exist with corticosteroid-re-sponsive dermatoses,and,for this reason,remain neglect-ed.thus,any epidemiological study may underestimate the real prevalence of CD.another prominent obstacle in defining the prevalence of CD is the agreement between different patch test sets,especially for irritant substances(e.g.formaldehyde);furthermore,the sometimes imper-fect reproducibility of results may also affect the overall diagnoses.12,13Irritant CD(ICD)is by far the most common type of CD,as it is estimated to represent about 80%of total cas-es;it is mainly caused by degreasing agents,cosmetics,dust,foods,solvents,excessive use of soap and water.12 for which concerns allergic CD(aCD),alinaghi et al.,in a recent metanalysis of 28 studies,found that 20.1%of the COPYRIGHT 2022 EDIZIONI MINERVA MEDICAThis document is protected by international copyright laws.No additional reproduction is authorized.It is permitted for personal use to download and save only one file and print only one copy of this Article.It is not permitted to make additional copies(either sporadically or systematically,either printed or electronic)of the Article for any purpose.It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems,electronic mailing or any other means which may allow access to the Article.The use of all or any part of the Article for any Commercial Use is not permitted.The creation of derivative works from the Article is not permitted.The production of reprints for personal or commercial use is not permitted.It is not permitted to remove,cover,overlay,obscure,block,or change any copyright notices or terms of use which the Publisher may post on the Article.It is not permitted to frame or use framing techniques to enclose any trademark,logo,or other proprietary information of the Publisher.guarnerI non-PHarmaCologICal treatment of eCZema404 ItalIan Journal of Dermatology anD Venereology october 2022 ual factors.33-36 typically,lesions are not well-demarcat-ed,35,36 bilateral(sometimes asymmetrical and prevalent in the dominant hand),and initially affect the back of the fingers and the interdigital folds,progressively extending to the back of the hands and then to the palms.The exten-sor surface of the forearms may be involved,but the volar surface of the wrists is usually spared.34Lesional skin appears moderately erythematous,xe-rotic and fissured;lichenification and fine or lamellar des-quamation may be present(figure 2).these aspects are typical of“wet workers”.In some patients,hyperkeratotic forms with painful ragadiform fissures may develop,and severely affect quality of life.acropulpitis is frequent in shoemakers and workers who handle small metal compo-nents;in these cases,thickening of the stratum corneum is favored by friction or traumatism,and may be respon-sible for the disappearance of fingerprints.37 exudation,blistering and crusted elements are less frequent.35 oc-casionally,chronic ICD of the hands may manifest with patches of nummular eczema located mainly on the dorsal surface(e.g.in the case of occupational exposure to cut-ting oils).35 another peculiar picture is apron dermatitis,characterized by erythema,xerosis and fissures on the palmar surface of 2-3 adjacent fingers,with semicircular extension on the palm.In chronic forms,ICD may also cause onycholysis,longitudinal striae or lamellar onycho-schizia.38for which concerns symptoms,ICD is characterized by a burning or stinging sensation,sometimes associated with pain.Itching may occasionally be intense and disabling.33one-year prevalence is between 1.2%and 17.1%,lifetime symptom prevalence is between 3%and 17.7%,one-year incidence is between 6.27 and 8.74 per 1,000 person years.30Hand eczemaas in the case of CD,several studies suggest that epide-miological data concerning HE are likely underestimated:in detail,only two thirds of patients affected by He refer to a physician for proper advice and treatment,and less than a half(44%or less)to a dermatologist.3,32according to literature,the estimated point prevalence of He in the general population is around 4%,while one-year prevalence is approximately 10%.3,32 lifetime preva-lence is slightly higher,i.e.11.3%.32 Incidence is 5.5-8.8 cases per 1000 person-years,with a higher rate in females and substantially no difference between adolescents and adults.3,32Clinical aspectsIrritant contact dermatitisacute ICD is caused by exposure to an irritant or a caustic.lesions develop soon after contact and are strictly con-fined to the exposed areas.Clinical manifestations(Fig-ure 1)range from mild inflammation(erythema,oedema)to vesiculation,bullae and/or necrosis.manifestations of chronic ICD may vary,depending on nature and concen-tration of the irritant,frequency of exposure and individ-figure 1.acute irritant contact dermatitis of the hands.COPYRIGHT 2022 EDIZIONI MINERVA MEDICAThis document is protected by international copyright laws.No additional reproduction is authorized.It is permitted for personal use to download and s