Letter to The Editor on 'Evaluation of antimicrobial textiles for atopic dermatitis'.

Recently, JEADV published an article titled ‘Evaluation of antimicrobial textiles for atopic dermatitis’ giving an assessment on ten silver‐coated and one non‐silver AEGIS‐coated (DermaSilk) textiles in one group and two untreated textiles as control group.1

There seems to be a major bias in this study design because the mechanism of action of the coated garments are different, not comparable, and should not be analysed as part of the same trial group. Silver‐containing textiles distribute ions to the skin; thus, evolving antibacterial properties, AEGIS‐coated textiles, such as DermaSilk, do not distribute ions, their mechanism of action is different. They simply inactivate micro‐organisms on infected skin and mucosa when they come in contact with the fabric, thus even after washing because the antimicrobial is silanized on the fabric.2 Apparently, this work does not refer to the recent literature concerning AEGIS‐coated products. As there have been clinical studies on DermaSilk since 2006, for several indications showing good results not only in atopic dermatitis, but also in lichen sclerosus, diabetic ulcers, vulvovaginal candidosis and acne vulgaris, Steinmann even proved DermaSilk comparable to topical corticosteroid in relieving symptoms of atopic dermatitis.3

Furthermore, the study uses the wrong ISO standard for the measurement of antibacterial activity. They used international standard ISO 22196 (JIS 2801) used for plastics and other non‐porous surfaces which actually does not apply to antibacterial‐treated textile products, as they are covered by ISO 20743.4 This error invalidates any results. Lastly, the authors discuss the results of CLOTHES‐trial5 and it′s sized down PLoS version.6This study shows some bias even in the recruiting phase as they included 300 children by their eligibility measured according to the Nottingham Eczema Severity Score (NESS) >9 denoting moderate to severe disease over the last 12 months. NESS was taken in account for the recruitment of patients, otherwise, when, for example, using Eczema Area and Severity Index (EASI) >7 at baseline, perhaps the recruitment phase would have taken much longer. This could also have led to a broad variation in eczema severity at baseline, as there was a wide range of severity measured with EASI score from 4.2 to 12.0 at baseline. If they would have been recruited by their eligibility measured according to the EASI >7 at baseline, the results would be much more diagnostically conclusive than shown here. A second bias also in this study emerges by not distinguishing between zinc‐coated and AEGIS‐coated textiles. After that, the children were randomized in two groups, one offering standard topical treatment (STANDARD) and one offering standard treatment plus the interventional garment (INTERVENTION) using two different kinds of interventional products: one AEGIS‐coated (DermaSilk) and one zinc‐coated (DreamSkin). That appears not justifiable because the two products have different modes of action, and therefore, they should not be mixed up one group. For the evaluation of itching and sleep loss as major symptoms of moderate to severe atopic eczema, the Patient‐Oriented Eczema Measure (POEM) is a useful tool for the measurement of treatment outcomes even if EASI scores do not change. Statistically significant POEM results observed in the study were dismissed by the authors. POEM evaluation should have been taken into account. Altogether, this study design does not apply to good clinical practice standards.

In the guidelines for the treatment of atopic dermatitis of 2012, published in JEADV, textiles coated either with silver7 or AEGIS ADM 5772/S8 are recommended for reduction of Staphylococcus aureus colonization and eczema severity, but it has been mentioned that these new options are still under investigation and stated ‘Of note, there is some concern about the safety of silver‐coated textiles in infants and toddlers’.9 In the US Atopic Dermatitis Guidelines published 2014 in JAAD, textiles were not recommended as there are still ‘gaps in research to be closed’. Finally in the new European Dermatology Forum guidelines part I, published 2018, all coated textiles with antimicrobial activity are not recommended any more without respect of their different mode of action.10 In our opinion, this ejects AEGIS‐coated textiles from the market, even if they have been proved for amending symptoms of various dermatological conditions in several newer studies.3 Thus, because they were thoughtlessly evaluated together with zinc‐coated products in a negligent study design, as there were two different fabrics DermaSilk and DreamSkin evaluated in one interventional group.5, 6

No funding sources supported this work.