Disinfectant therapy to staphs on atopic skin and the topical steroid resistance (TSR)

I don’t know if the same kind of therapy exists in other countries than Japan. I have never found the similar therapy in other countries by the Pubmed (medical scientific article sauce, http://www.ncbi.nlm.nih.gov/pubmed).

The disinfectant therapy includes various methods.Theoretically there are as many methods as the number of disinfectants. Anyway, the disinfectant therapy means applying a certain disinfectant to the patient’s skin, waiting for a while (usually a few minutes) and washing the disinfectant away by shower. That is all.

Povidon-iodine and electrolyzed strong acid aqueous solution are both preferable disinfectants. Do you know the electrolyzed strong acid aqueous solution? It became popular in 90’s in Japan in the medical field. It is because the problem of MRSA (Methicillin-resistant Staphylococcus aureus) emerged at that time. The staphs could be sterilized by oral antibiotics more effectively than disinfectant but it would also increase the risk of emersion of MRSA. So various trials were done at that time in Japan and use of the electrolyzed strong acid aqueous solution in the medical field was one of them.

By search of Pubmed, I couldn’t find any article about the electrolyzed strong acid aqueous solution by non-Japanese researcher. So I am not sure if it is also used in the medical field in other countries. The solution is produced from the tap water, a bit of salt (NaCl) and a kind of electric device (Figure below).

The electrolyzed water around anode indicates low value in pH. The acid water below 2.7 in pH is the electrolyzed strong acid aqueous solution. It sterilizes every kind of bacteria nonspecifically.  The shortage is that the solution is unstable. So it is recommendable to purchase the device itself.  The device costs about JPN 50-100 thousand (USD about 500-1,000). The price differs by provider or the time to purchase. In fact, I have my own device in my clinic too. I sanitize environments around my operation room by that solution.

For atopic dermatitis, the below illustration will help you to comprehend the procedure. The illustration is from a brochure of a provider of the electrolyzed strong acid aqueous solution.

The solution doesn’t irritate the skin at all although its pH is very low. It is because the solution becomes just oxidized by the contact to the skin. It reduces the very superficial layer of the skin and bacteria to disinfect. The action is so instantaneous that it never damages the substantial skin. It is recommendable even for infants and children. And you don’t need to wash the solution away in several minutes like other disinfectants.

Povidone-iodine 10% solution is another disinfectant commonly used for the treatment of atopic dermatitis. It was first put forward in 1990 by Sugimoto, a pediatrician in Japan. He has written several medical articles about the method.

New successful treatment with disinfectant for atopic dermatitis. Dermatology 1997; 195(suppl 2):62–68.

The Importance of Bacterial Superantigens Produced by Staphylococcus aureus in the Treatment of Atopic Dermatitis Using Povidone-Iodine. Dermatology 2006;212(suppl 1):26–34

The photos below is the procedure.

First the patient applies povidone-iodine 10% solution directly to the skin. Note that there are many povidone-iodine liquid products. Some of them contains alcohol (for gargle) or detergents (for hand wash) and are not suitable for this therapy. Only 10 % simple aqueous solution can be used.

After 2-3 minutes the patient washes the disinfectant away completely by shower. The patient then applies emollients like simple white petrolatum. That is all.

Comparing the above two disinfectants, the strength as a disinfectant is maybe larger in povidone-iodine. But the stimulus is also more in povidone-iodine. Moreover, the povidone-iodine has the risk of sensitization while the electrolyzed strong acid aqueous solution does not. So I recommend the electrolyzed strong acid aqueous solution for patients who are not under skillful dermatologists.

The biggest problem of staphs on atopic skin is that it can cause the topical steroid resistance (TSR). Staphs produce a kind of toxins and they effect as superantigens which accelerate immune reaction nonspecifically. The patient who suffers from TSR develops ineffectiveness to topical steroids. The patient present very similar skin symptom to TSA and sometimes TSR is accompanied with TSA.

Here is a case with TSR and TSA. His eczema relapsed at the age of 18 after long remission period from infancy. The amount of TS prescribed in the former dermatologist for 5 years before the first visit to me is as follows.

age	Amount of TS (gram per year)
23	1595
24	1665
25	2178
26	1650
27	890

The patient reacted to TS at first but became to feel ineffectiveness since 27 years old. So the patient discontinued. The patient was introduced by the former dermatologist to me because of difficulties in treatment. The appearance of the patient at first visit was as the below photo.

How do you think his skin manifestation? It is so-called erythroderma but the point is that his skin manifestation consisted of very few elements. That is, the element was almost erythema only. In such a case, the TSA is not so severe. If he had various elements, especially prurigo, I judge his TSA is severer.

There are two possibilities of his ineffectiveness to TS; TSA and TSR.
You may say there is a possibility of contact dermatitis to TS or emollient etc. But the patient came to me after four months’ discontinuance of TS and he had never applied anything to the skin for that period. If he suffered from contact dermatitis to something, He must have recovered at that time. So contact dermatitis is excluded.

I examined the staphs on the skin by culture. There were enormous number of staphs. So I recommended the disinfectant therapy using povidone-iodine. Staphs cause TSR and worsen the dermatitis itself. Such patients may develop steroid-resistant dermatitis.

The above photo is one month after the first visit.

 

The above is three months after the first visit.

 The above is 6 months after the first visit.

 8 months

 10 months

1 year

1 year and three months after the first visit. He had never used any medication except for disinfectant and white petrolatum. So it is his original skin. The eruption seen at the first visit was TSR accompanied with TSA and was not of his original eczema.
The below is a flow chart summary for the better understanding.

Be smart and wise enough not to fail to recognize your own situations. Because only you can know the whole procedure of eczema and judge correctly.


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