mycoses Diagnosis,Therapy and Prophylaxis of Fungal Diseases

Original article

Topical antifungal-corticosteroid combination therapy for the

treatment of superficial mycoses: conclusions of an expert panel
meeting

Martin Schaller,1 Markus Friedrich,2 Manuela Papini,3 Ramon M. Pujol4 and Stefano Veraldi5
1
Department of Dermatology, University Hospital Tu€bingen, Tu€bingen, Germany, 2Hautarztpraxis Oranienburg, Oranienburg, Germany, 3Department of
Surgery and Biomedicine, University of Perugia, Perugia, Italy, 4Department of Dermatology, Hospital del Mar, Barcelona, Spain and 5Department of
Pathophysiology and Transplantation, Universita degli Studi di Milano, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Foundation, Ca Granda
Ospedale Maggiore Policlinico, Milan, Italy

Summary Superficial fungal infections affect 20–25% of people worldwide and can cause con-
siderable morbidity, particularly if an inflammatory component is present. As superfi-
cial fungal infections can be diverse, the treatment should be tailored to the
individual needs of the patient and several factors should be taken into account
when deciding on the most appropriate treatment option. These include the type,
location and surface area of the infection, patient age, degree of inflammation and
underlying comorbidities. Although several meta-analyses have shown that there
are no significant differences between the numerous available topical antifungal
agents with regard to mycological cure, agents differ in their specific intrinsic proper-
ties, which can affect their clinical use. The addition of a corticosteroid to an anti-
fungal agent at the initiation of treatment can attenuate the inflammatory
symptoms of the infection and is thought to increase patient compliance, reduce the
risk of bacterial superinfection and enhance the efficacy of the antifungal agent.
However, incorrect use of antifungal-corticosteroid therapy may be associated with
treatment failure and adverse effects. This review summarises available treatment
options for superficial fungal infections and provides general treatment recommenda-
tions based on the consensus outcomes of an Expert Panel meeting on the topical
treatment of superficial mycoses.

Key words: Superficial fungal infection, antifungal, corticosteroid, combination therapy.

in socioeconomic conditions, lifestyle, migration and

Introduction
Superficial fungal infections are one of the most fre-
quent forms of infection encountered in medicine, with
20–25% of people worldwide affected at any given
time.1 This prevalence is increasing, reflecting changes
Correspondence: M. Schaller, Department of Dermatology, University
€bingen, Liebermeisterstrasse 25, 72076 Tu
Hospital Tu €bingen, Germany.
Tel.: +49 7071 298 4555. Fax: +49 7071 295 113.
E-mail: martin.schaller@med.uni-tuebingen.de
Submitted for publication 7 October 2015
Revised 19 January 2016
Accepted for publication 19 January 2016
medical practices. In particular, the use of intensive
chemotherapy and immunosuppressive drugs are lead-
ing to a growing population of immunocompromised
individuals.2 Although not life-threatening, superficial
fungal infections can often cause considerable morbid-
ity, especially if a severe inflammatory component is
present.3
Superficial fungal infections affect the human hair,
nails, epidermis and mucosa, and are most commonly
caused by dermatophytes, which are obligate patho-
gens requiring keratin for survival.4,5 Less frequently,
they can be caused by non-dermatophyte moulds or
Candida species.4 Dermatophytes can be classified as

© 2016 Blackwell Verlag GmbH

Mycoses, 2016, 59, 365–373 doi:10.1111/myc.12481
M. Schaller et al.
anthropophilic, zoophilic or geophilic, depending on
their primary habitat (humans, animals and soil
respectively). The clinical picture of dermatomycoses is
variable due to the degree of keratin destruction by
the fungus and the inflammatory response of the host.
It has been observed that the more adapted the der-
matophyte is to its human host, the milder the result-
ing inflammatory response will be.5,6 For example,
anthropophilic dermatophytes cause little inflamma-
tion but can cause recurrent or chronic infections,
while zoophilic and geophilic dermatophytes tend to
induce acute and highly inflammatory responses.5,6
Inflammatory symptoms such as pruritus, erythema,
swelling and burning, can have a significant impact
on the quality of life of the affected individual.
Treatment decisions are typically based on clinical
observation and mycological diagnosis using classical
tests such as direct microscopy and fungal culture.
Modern molecular biology diagnostic techniques such
as polymerase chain reaction may also be used.7
Although both systemic and topical antifungal agents
are available, topical therapies are generally favoured
over systemic agents for the treatment of superficial
infections, especially when the infection is limited to
hair-free skin.8 In contrast to systemic treatment,
topical antifungal therapies limit the risk of systemic
side-effects and drug–drug interactions, do not require
laboratory tests to monitor the treatment, and enable
the treatment to be directly targeted to the site of the
infection.8
Antifungal-corticosteroid combinations may be par-
ticularly beneficial for patients with symptomatic
inflammatory superficial infections, as they can rapidly
attenuate the inflammatory symptoms while simulta-
neously leading to mycotic healing.
Due to the diverse nature of superficial fungal infec-
tions, there is a need to provide guidance to clinicians,
both dermatologists and non-dermatologists, on the
most appropriate treatment options for different infec-
tion types and patient populations. In December 2014,
a panel of experts met in Berlin, Germany to discuss
the topical treatment of superficial fungal infections.
This report summarises their recommendations based
on personal clinical experience, and taking into
account the presentation of the fungal infection and
patient characteristics.
Available topical antifungal agents
Superficial fungal infections can usually be effectively
managed with topical antifungal agents alone,9 a
number of which are currently available. The addition
366
of a systemic antifungal agent may be required in cer-
tain cases, such as in fungal infections of the scalp or
nails, infections over a large body surface area or with
multiple lesions, or in cases of chronic infection.
Various systematic reviews and meta-analyses inves-
tigating the safety and efficacy of topical antifungal
agents in the treatment of cutaneous fungal infections
have shown that there are no significant differences
between the various available antifungal agents with
regard to safety, tolerability and mycological cure.10–13
However, they do differ in their specific intrinsic
properties, which can affect their clinical use.
Topical azoles
Topical azoles (e.g. clotrimazole, bifonazole and iso-
conazole) are the mainstay of treatment for dermato-
mycoses and are the most widely used antifungal
agent, due to their proven efficacy and affordability,
and over-the-counter availability.14 They are usually
administered for 2–4 weeks, and a number of topical
azoles, such as clotrimazole, have been approved in
the USA and Europe for the treatment of superficial
fungal infections in both adults and children.15,16
They provide broad-spectrum antifungal coverage with
activity against dermatophytes, moulds, yeasts and
some Gram-positive and Gram-negative bacteria.14,15
Although there are no significant differences in effi-
cacy among the different agents within the azole
class,12 they do differ with regard to their antibacterial
properties, treatment duration and intrinsic anti-
inflammatory activity. The properties of commonly
used topical azoles are summarised in Table 1.
Allylamines
Allylamines (e.g. terbinafine and naftifine) have potent
activity against dermatophytes and variable activity
against yeast and moulds.23 They also have some
intrinsic anti-inflammatory activity, and some can be
obtained over the counter.24,25 However, they are not
recommended for use in paediatric patients.24,26
Although allylamines have been shown to have a
higher sustained cure rate and reduced treatment
course in comparison with azoles,12 due to their signif-
icantly higher acquisition cost,10 they are generally
reserved for second-line treatment if azoles fail.
Morpholines and ciclopirox
Morpholines (e.g. amorolfine and butenafine) and
ciclopirox are highly potent, broad-spectrum
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Mycoses, 2016, 59, 365–373

Table 1 Summary of the specific properties of commonly used topical azoles.
Clotrimazole15
Treatment duration 2–4 weeks
Frequency of application 2–3 times a day
Antifungal effects Fungistatic, fungicidal
at high concentrations
Anti-inflammatory properties No
Antibacterial activity (in vitro) Gram-positive and
Gram-negative cocci20
MRSA, methicillin-resistant Staphylococcus aureus.
antifungal agents with additional antibacterial activity
against some Gram-positive and Gram-negative bacte-
ria.27,28 They are not approved in children <10 years
of age.29–31 Ciclopirox also exerts anti-inflammatory
effects, similar to that of a mild corticosteroid.32
Polyenes
Polyenes (e.g. nystatin) are ineffective against der-
matophytes3, but highly effective against oral or cuta-
neous candidiasis.33 Nystatin has been approved in
the US and Europe for the treatment of superficial fun-
gal infections in children.34,35
Antifungal-corticosteroid combination
therapy
During a superficial fungal infection, the degradation
of keratin (via the release of keratinases and the liber-
ation of other pathogenic factors by the fungus)
induces a first-line immune response and the subse-
quent release of pro-inflammatory cytokines. This
causes the typical inflammatory symptoms, such as
pruritus, erythema, swelling and burning at the site of
infection. Not only can these symptoms cause consid-
erable discomfort and decrease patient adherence to
treatment, but the induced scratching can increase the
spread of infection and also leave the skin damaged
and vulnerable to bacterial superinfections.
Due to their anti-inflammatory, immunosuppressive,
antimitotic and vasoconstrictive actions, topical corti-
costeroids play an important role in the treatment of
various inflammatory skin diseases.36 In particular,
antifungal-corticosteroid combination therapy is a
treatment option for superficial fungal infections with
an inflammatory component.
An increasing number of international guidelines
recommend the use of combination products consist-
ing of an antifungal agent and a corticosteroid, such
© 2016 Blackwell Verlag GmbH
Mycoses, 2016, 59, 365–373
Topical treatment for superficial mycoses
Bifonazole17 Isoconazole18
2–3 weeks 2–3 weeks and up to 4 weeks
in persistent infections
Once-daily Once-daily
Fungistatic, fungicidal against Fungistatic and fungicidal
Trichophyton and Candida spp.
Yes19 No
Gram-positive cocci19 Gram-positive bacteria (including MRSA)21,22
as hydrocortisone or diflucortolone valerate, to provide
rapid symptomatic relief of inflamed superficial fungal
infections.37 It is recommended that an antifungal-cor-
ticosteroid combination be administered at the initia-
tion of therapy for 1–2 weeks, followed by antifungal
monotherapy.37–39 This treatment regimen has been
shown to be effective in inflammatory tinea corporis,11
inflammatory tinea cruris,11 inflammatory tinea
pedis,40 or infections caused by zoophilic dermato-
phytes,41 which are known to trigger a strong inflam-
matory response.
By reducing inflammation and pruritus, topical cor-
ticosteroids can reduce the risk of secondary bacterial
superinfections, and reduce the spread of infection.
Moreover, by reducing the inflammatory component of
the infection, combination therapies have been shown
to enhance the efficacy of the antifungal agent,11,42
facilitate the restoration of the skin’s barrier function
and contribute to the normalisation of the bacterial
flora.42 They have also been shown to reduce the risk
of irritation and contact dermatitis that can sometimes
be associated with the use of topical antifungal
agents.43–46
The efficacy of antifungal-corticosteroid combination
therapy in comparison with antifungal monotherapy
has been demonstrated in a number of clinical trials.
Isoconazole-diflucortolone combination therapy has
been shown to be associated with a more rapid resolu-
tion of inflammatory symptoms, including pruritus,
erythema and scaling, than isoconazole monother-
apy.47 Additionally, isoconazole-diflucortolone combi-
nation therapy has been associated with a more rapid
onset of antimycotic action than isoconazole
monotherapy, and has therefore been shown to result
in higher mycological and clinical cure rates after
2 weeks of treatment.48
Despite these numerous benefits, some clinicians
have concerns regarding the use of antifungal-corti-
costeroid combination therapy in the treatment of
367
M. Schaller et al.
superficial fungal infections. It has been suggested that
corticosteroids may interfere with the therapeutic
action of the antifungal agent, or increase fungal
growth as a result of decreased localised immune
response.49 However, a number of studies have
demonstrated that there is no significant difference in
the rate of mycological cure between antifungal-corti-
costeroid combination therapy and antifungal
monotherapy.11,50–52 Moreover, antifungal-corticoster-
oid combination therapy demonstrates more rapid
therapeutic activity, and has been shown to be more
effective in achieving clinical cure (the absence of
symptoms such as erythema and pruritus) than topical
antifungal therapy alone.11,50–52 Although topical
antifungals and corticosteroids are available as single
preparations, the availability of fixed combinations
offers clear benefits for both patients and physicians.
They not only ease physicians’ lives in their prescrip-
tion of drugs with regard to dosage, posology and
safety (adverse events, drug interaction), but also
patients’ lives by providing an improved convenience
(simpler posology by standardised doses, increased ease
of application). Thereby, patient’s treatment compli-
ance is encouraged, which in turn may lead to an
improved therapeutic outcome.
There have also been concerns regarding the safety
and tolerability of certain antifungal-corticosteroid
combinations, mainly due to the characteristics and
potency of the topical corticosteroid. Some local or
even systemic side effects have been documented, most
often linked to the misuse of combination therapy
such as the prolonged use of medium- to high-potency
corticosteroids, especially on the face, or use on large
surface areas or under occlusive conditions.49
Betamethasone, a fluorinated, highly potent corticos-
teroid, is sometimes prescribed by non-dermatologists
or primary care providers in combination with clotri-
mazole. However, clotrimazole-betamethasone has
been shown to be associated with a number of adverse
effects, including the suppression of the hypothalamus-
pituitary-adrenal axis, treatment failure, cutaneous
atrophy, tinea incognito and Majocchi granuloma
when used under occlusion or on large surface
areas.53 Consequently, clotrimazole-betamethasone is
not recommended for use in children <17 years of
age, in immunosuppressed patients, or for lesions
located in occluded areas.53 However, the safety and
tolerability of other antifungal-corticosteroid combina-
tions, such as isoconazole-diflucortolone and clotrima-
zole-hydrocortisone, have been investigated in a
number of superficial fungal infections in both adults
and children.47,48,54–56 Isoconazole-diflucortolone,
368
administered once-daily for 1–2 weeks followed by iso-
conazole monotherapy administered for 2–3 weeks,
has been shown to be a well-tolerated and effective
treatment regimen.47,48,54,56,57 Additionally, the
biphasic schedule of treatment (antifungal-corticoster-
oid combination therapy for 1–2 weeks followed by
antifungal monotherapy) may be an additional practi-
cal drawback.
To reduce the risk of adverse events, antifungal-cor-
ticosteroid combinations should be prescribed by
trained specialists and used judiciously in accordance
with licenced recommendations. They are not recom-
mended for use in some particular areas (such as the
face and scrotum), on large surface areas or for pro-
longed periods. Additionally, combination therapies
should be used with caution in intertriginous and nat-
urally or artificially occluded areas such as the per-
ineum, inguinal and axillary folds.53,58,59 To maximise
efficacy and tolerability, antifungal-corticosteroid com-
bination therapy should be used for 1–2 weeks at the
initiation of treatment, followed by antifungal
monotherapy if further treatment is required. This
treatment regimen is suitable for the treatment of
superficial fungal infections of the body (excluding the
face), the groin and the feet.
Although diflucortolone and betamethasone are
both Class III corticosteroids, and consequently provide
fast relief of inflammatory symptoms and pruritus,
diflucortolone has lower systemic absorption than
betamethasone, so is associated with a lower risk of
systemic side effects.60 It is therefore the preferred
treatment option for infections with a considerable
degree of inflammation. Hydrocortisone is a Class I
corticosteroid, and consequently exerts only weak
anti-inflammatory effects. Clotrimazole-hydrocortisone
is therefore often considered the preferred treatment
option in paediatric patients requiring combination
therapy, or for the treatment of infections with a mild-
to-moderate inflammatory component. The specific
intrinsic properties of clotrimazole-betamethasone,
clotrimazole-hydrocortisone and isoconazole-diflucorto-
lone are summarised in Table 2.
Treatment recommendations for the use of
antifungal-corticosteroid combination
therapy against superficial mycoses
General treatment recommendations based on the con-
sensus outcomes of the Expert Panel meeting on the
topical treatment of superficial mycoses for both adults
and children are discussed below and summarised in
Fig. 1. Typical examples of varying degrees of
© 2016 Blackwell Verlag GmbH
Mycoses, 2016, 59, 365–373
 Topical treatment for superficial mycoses

Table 2 Summary of the specific properties of available antifungal-corticosteroid combination therapies.

Clotrimazole-betamethasone53,1 Clotrimazole-hydrocortisone59,2 Isoconazole-diflucortolone58,1

Antimicrobial effects Fungistatic, fungicidal at Fungistatic, fungicidal Fungistatic and fungicidal

Antibacterial properties
(in vitro)
Anti-inflammatory properties
Frequency of application
Treatment duration
Precautions
Pregnancy
high concentrations
Gram-positive and
Gram-negative cocci20
Class III corticosteroid
Twice daily
Maximum 2 weeks for
tinea corporis or
tinea cruris. Maximum
4 weeks for tinea pedis
No extensive application,
no use under occlusion,
patients >17 years only
No use during pregnancy
at high concentrations
Gram-positive and
Gram-negative cocci20
Class I corticosteroid
Twice daily
Maximum 7 days
Avoid long-term
use on large areas
No use
during first trimester
Gram-positive bacteria including MRSA21,22
Class III corticosteroid with low systemic
absorption
Twice daily
Initial or interim for a maximum of 2 weeks
No extensive application, no use under
occlusion
No use during first trimester

MRSA, methicillin-resistant Staphylococcus aureus.

1
Prescription.
2
Over-the-counter.

inflammation observed in superficial mycoses are illus-

trated in Fig. 2. These recommendations are appropri-
ate for immunocompetent patients only. The use of
antifungal-corticosteroid combination therapy is not
recommended in immunocompromised patients, as
dermatophytes tend to invade deeper tissues in these
individuals.49
In general, initial twice-daily topical antifungal-cor-
ticosteroid combination therapy for 1–2 weeks, is rec-
ommended in localised, inflammatory, superficial
fungal infections of the body (excluding the facial
area), groin (sparing the inguinal folds) and feet. For
infections with a moderate inflammatory component,
combination therapy with a mild corticosteroid, such
as clotrimazole-hydrocortisone, is usually sufficient.
For severely inflamed infections, combination therapy
with a potent corticosteroid, such as isoconazole-diflu-
cortolone, is recommended. Isoconazole-diflucortolone
has been shown to be suitable for use in chil-
dren.47,48,61 However, clotrimazole-hydrocortisone or
an antifungal agent with intrinsic anti-inflammatory
activity, are the preferred treatment options of the
expert panel in paediatric patients with inflammatory
superficial mycoses. The use of topical hydrocortisone
in children has been shown to be generally well-toler-
ated with a favourable safety profile.62–65 For infec-
tions with a mild inflammatory component, treatment
with a topical antifungal monotherapy with intrinsic
anti-inflammatory activity, such as bifonazole, is
recommended.
Location of the fungal infection
Feet
Tinea pedis is the most common dermatophyte infec-
tion in adults and is particularly prevalent in patients
with diabetes, who are 2.5–2.8 times more likely to
contract foot mycoses than those without the
disorder.66,67 Topical azoles are recommended for its
treatment due to their broad antifungal spectrum,
additional antibacterial properties and possible intrin-
sic anti-inflammatory activity. Some of them, such as
bifonazole, have the additional advantage of a
once-daily treatment regimen.17 As mixed infections
frequently occur,68 the use of a topical azole with
additional antibacterial activity is recommended.
Inflammation is often considerable,69 and therefore,
treatment with an antifungal-corticosteroid combina-
tion therapy may be beneficial for 1–2 weeks at the
beginning of treatment.58
Tinea pedis is also a major risk factor for ony-
chomycosis and secondary bacterial infections,68
which may lead to serious complications, especially
in immunocompromised or diabetic patients.68 It is
also a risk factor for cellulitis, particularly if the
infection affects the interdigital area.68 Consequently,
early initiation of treatment is essential. As reinfec-
tion is also common,70 it is important to educate
patients on preventative measures, to keep feet dry
and eventually applying a topical antifungal cream
bi-weekly.

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Mycoses, 2016, 59, 365–373 369
M. Schaller et al.

Figure 1 Consensus view on the use of antifungal-corticosteroid combination therapy in (a) adults and (b) children based on the loca-
tion and surface area of the infection and the degree of inflammation. Combination therapy = antifungal + corticosteroid; TAM, topical
antifungal monotherapy. Purple indicates the area of infection.

Nails superinfection and increase patient adherence to

The use of antifungal-corticosteroid combination ther-
apy is not appropriate for the treatment of fungal
infections of the nails since no inflammatory symp-
toms are present.
Groin
Tinea inguinalis is often associated with severe
burning and pruritus, and therefore, topical treat-
ment with an antifungal-corticosteroid combination,
such as isoconazole-diflucortolone, is often required.
As the corticosteroid rapidly reduces the severity of
pruritus, this can reduce the risk of bacterial
treatment.71 The prolonged use of antifungal-corti-
costeroid combination therapy may lead to cuta-
neous adverse effects such as striae distensae when
applied to flexural and humid areas,72 and therefore,
should only be used for short treatment periods
(≤2 weeks).
Scalp
Tinea capitis is the most common fungal infection in
children.9 In the treatment of tinea capitis, an oral
antifungal treatment is usually required in order to
penetrate hair follicles. The use of topical antifungals

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370 Mycoses, 2016, 59, 365–373

Figure 2 Typical examples of varying degrees of inflammation observed in superficial mycoses.
as an adjunct therapy is recommended to reduce the
transmission of spores.73 In highly inflammatory tinea
capitis, such as Kerion Celsi, the addition of a topical
corticosteroid may be required to reduce scaling and
pruritus.
Skin regions other than the scalp, groin, hands and feet
In the treatment of tinea corporis, if the infection is
localised or only solitary lesions are present, treatment
with a topical antifungal agent is usually sufficient.
When an extensive surface area is involved or when
multiple lesions are present, systemic treatment may
be required. In cases where an inflammatory compo-
nent is present, treatment with an antifungal-corticos-
teroid combination may be beneficial. However,
isoconazole-diflucortolone should be used with caution
when administered to large areas of the body, particu-
larly those under occlusion.
It is worth noting that the number of children with
atopic dermatitis is increasing and a significant num-
ber of children presenting with tinea corporis are
affected by the disorder.74 In children with tinea cor-
poris and atopic dermatitis, bacterial superinfections,
predominantly with Staphylococcus aureus, are likely to
occur. In these cases, the use of an antifungal agent
which also has antibacterial activity, such as isocona-
zole, may be beneficial. However, treatment with an
antifungal-corticosteroid combination can reduce the
risk of bacterial superinfection by targeting the root
cause. The use of corticosteroids in atopic dermatitis
has been shown to reduce bacterial colonisation with-
out the use of antibiotics.75
Conclusions
Superficial fungal infections are diverse and symptoms
can range from mild erythema to severe inflamma-
tion and pruritus with bacterial superinfection. The
© 2016 Blackwell Verlag GmbH
Mycoses, 2016, 59, 365–373
Topical treatment for superficial mycoses
treatment of superficial fungal infections should,
therefore, be tailored to the individual needs of the
patient. There are numerous topical antifungal agents
available for the treatment of superficial fungal infec-
tions, with varying intrinsic properties. A number of
topical agents are available as a monotherapy or in
combination with corticosteroids of varying potencies.
The choice of treatment regimen will depend on the
specific characteristics of the infection (such as loca-
tion, surface area and degree of inflammation) and
the specific characteristics of the patient (such as age
and the presence of underlying comorbidities, such as
diabetes). Topical antifungal agents are usually suffi-
cient in the treatment of superficial fungal infections,
however, systemic therapy may be required in
chronic infections or if an extensive surface area is
affected. If inflammation is present, initial short-term
treatment with an antifungal-corticosteroid therapy
may be beneficial in both adults and children, fol-
lowed by treatment with a topical antifungal agent
alone. Although there seems to be no significant dif-
ference in mycological cure rates between antifungal-
corticosteroid combination therapy and antifungal
monotherapy, a more rapid onset of antimycotic
action and a more rapid resolution of inflammatory
symptoms have been observed with combination ther-
apies. This prompt symptom relief may also lead to
increased adherence to treatment and may reduce
the risk of secondary bacterial superinfections. Combi-
nation therapies are particularly valuable in situations
where inflammatory symptoms are observed most fre-
quently, such as in diabetic patients with foot
mycoses, in children with tinea corporis and atopic
dermatitis and in infections caused by zoophilic der-
matophytes. When used appropriately, combination
therapy has been shown to be well tolerated and
effective in the treatment of inflammatory superficial
mycoses.
371
M. Schaller et al.
Acknowledgments
Medical writing support was provided by Alex Mellors,
Core Medica, London, UK, funded by Bayer Consumer
Care.
Disclosures
All authors received travel compensation and hono-
raria for attendance at the expert panel meeting
funded by Bayer Consumer Care AG. Employees of
Bayer Consumer Care AG were permitted to read
drafts of the manuscript and offer comments, but the
final content, and the decision to publish this manu-
script, was at the discretion of the authors. Professor
Dr Martin Schaller was a member of the advisory
board during the past 2 years and has received lecture
fees from Abbvie, Bayer Consumer Care AG, Galderma,
Marpinion and La Roche Posay. Markus Friedrich was
a member of advisory boards during the past 2 years,
and has received lecture fees from Abbvie, Bayer Con-
sumer Care AG, Galderma, Almirall, Norvartis and
Meda. Manuela Papini and Ramon M. Pujol have no
additional disclosures to declare. Stefano Veraldi has
received lecture fees from Avantgarde, Bausch and
Lomb/Valeant, Bayer Consumer Care AG, Biogena
Valetudo, Cieffederma, Devital Service, Difa Cooper,
Fidia, Meda Pharma, Menarini Asia Pacific, Pierre
Fabre, Visufarma.
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