the pathogenesis of atopic dermatitis ( ad ) remains to be studied but recently a possible change in the immune system with production of immunoglobulin e ( ige ) and immunoglobulin g ( igg ) is proposed . this disease is known with pruritus , eczematous lesions , dry skin , skin thickening , and prominent ridges of the skin . ad may be related to other diseases such as asthma , hay fever , and hives . the disease epidemic is growing and , 15 - 30% of the children in the developed countries and 10 - 20% of adults suffer from ad . the prevalence of the disease is high in immigrant people from developed to developing countries . , there is a balance between t helper 1 and t helper 2 . in patients with ad , the t helper 2 , increases and the result is high levels of ige and interferon - gamma , which are low . the second hypothesis is the stratum corneum skin barrier dysfunction associated with ad . in this case children with ad have more behavioral and psychological problems than the healthy children . living with ad has a profound effect on the quality of life for these children and their families . in turn , improper quality of life in these children is reported equally or more frequently compared to the people with asthma and diabetes . persistent itching and the absence from work in adults cause a large economic burden , and due to their resistance to conventional therapies , ad patients face recurrence of clinical and social problems . most people are discouraged after trying various treatments , including antihistamines , steroids , and cyclosporine a. vitamin e is known for its antioxidant properties and is found to have a protective effect on common health problems as heart disease , cataracts , cancer , and stroke . recent studies have also shown that vitamin e can reduce the level of ige antibodies in patients with ad . given that the treatment with vitamin e is safe and cost - effective , the aim of the current study was to investigate the effect of vitamin e on the treatment of ad . this study was conducted as a double - blind , randomized controlled trial ( rct ) ( trial registry code : irct201105016350n1 ) . a total number of 70 known cases of ad were randomly selected from those patients were referred to the dermatology clinics of two teaching hospitals ( alzahra and noor ) affiliated to isfahan university of medical sciences , isfahan , iran . the trial was approved by the research and ethics committee , skin and leishmaniasis research center , isfahan university of medical sciences . written informed consent was obtained from all the participants . those cases were selected that were aged 10 - 50 years , and their disease was confirmed based on hanifin and rajka diagnostic criteria . the patients who matched the following criteria were not recruited to the trial : severe disease with a scorad score of more than 50 , requiring hospitalization , pregnant women , nursing mothers , coagulopathies , using anticoagulant medications , systemic corticosteroids or immunosuppressant , as well as having a history of allergy to vitamin e , and living in long distances from isfahan city . those patients who showed severe allergic symptoms to vitamin e and those who became pregnant during the therapy were excluded from this trial , and they received standard treatment . all the patients received the usual treatment for ad , including children vaseline ( firooz company , iran ) , glycerin soap ( ejhe company , iran ) , hydroxyzine tablets ( daroopakhsh company , iran ) and topical hydrocortisone cream 1% ( tehran daroo company , iran ) . the selected 70 patients were assigned in two groups of equal number ( simple randomization ) : one group received vitamin e 400 units ( nature company ) and the other group received placebo . the placebo had no active ingredient and was without smell ; it was packed in the same package as vitamin e. clinical evaluation was conducted by the scorad index , which is a combined index consisting of the observable objective criteria , the extent and severity of injuries , as well as subjective criteria as itching and loss of sleep . the lesion extent was composed of six measures as follows : redness ( erythema ) edema / papules ( solid lesion , leading to less than 5 mm in size ) , rash symptoms ( excoriation ) , prominent ridges and thickening of skin horny layer of epidermis lichenification ) , serous fluid secreted from the epidermis ( oozing ) , or curd made ( crusts ) , which were scored from 0 to 3 . scorad index formula is defined as : a/5 + 7b/2 + c , in which : a is the lesion extent of the area and considered from 0 to 10 , b is the intensity of the lesion and considered from 0 to 18 , and c is the subjective symptoms counted from 0 to 20 . the total score is 103.the extent of the lesion is ranked 0 - 100 and for assessment , in the area of measurement we draw the line and after that , the size of the involved surface area is calculated with the help of the rule no . 9 and then the results are collected . for assessing the severity of the lesion , the surface that is the main cause and the reason of referring patients , is considered and to measure the subjective symptoms , a ruler scaled from 0 to 10 is used in order to determine the severity of the symptoms . types of eczema , are defined as follows : 
 mild eczema score on the scorad index is less than 25 ; for example , mild skin dryness and itching.median eczema score on the scorad index is more than 25 and less than 50 ; for example , the average skin redness , itching , sleep disturbance , and the secondary infection of skin ( mild to median).severe eczema score on the scorad index is more than 50 ; for example , severe skin redness , severe itching , insomnia , raised ridges of skin , thickening of the horny layer of the epidermis secondary severe skin infection . patients with scorad index of more than 50 were not enrolled in this trial . mild eczema score on the scorad index is less than 25 ; for example , mild skin dryness and itching . median eczema score on the scorad index is more than 25 and less than 50 ; for example , the average skin redness , itching , sleep disturbance , and the secondary infection of skin ( mild to median ) . severe eczema score on the scorad index is more than 50 ; for example , severe skin redness , severe itching , insomnia , raised ridges of skin , thickening of the horny layer of the epidermis secondary severe skin infection . each month , the severity , extent of lesions , and the overall subjective appearance of the patients ( insomnia and pruritus ) were measured by using the scorad index , and recorded daily . also every two weeks , the patients telephone were followed up to check out any unusual symptoms , side effects , worsening of symptoms , and how to use oral vitamin e , were performed and recorded . three months after the treatment , rates of relapse ( return of at least 50% of the eczematous lesions on the scorad index ) was evaluated . during the treatment period , two people from the group receiving vitamin e and three from the placebo group quitted the trial because of personal reasons . data analysis was conducted by statistical package for the social sciences ( spss ) version 12 for windows ( spss inc . , data analysis was conducted by statistical package for the social sciences ( spss ) version 12 for windows ( spss inc . , the male - to - female ratio was similar 43% vs. 57% in both groups [ table 1 ] . as presented in table 2 , the mean score for sleep disturbance or sleeplessness and itching lesions in the group receiving vitamin e and the mean total score of the scorad index were negative in both groups . distribution of study population study according to gender mean scores of different variables in vitamin e - treated and placebo groups itching , extent of lesions , and scorad index improvement was significantly higher in vitamin e treated group compared to placebo group ( 1.5 vs. 0.218 in itching , 10.85 vs. 3.54 in extent of lesion , and 11.12 vs. 3.89 in scorad index , respectively , p < 0.05 ) . the highest reduction in total score of scorad index , and lowest reduction of sleep disturbance or sleeplessness score was observed in the placebo group . in the group receiving vitamin e , the total average differences in all measured variables were negative , which shows favorable response to vitamin e therapy . as presented in table 3 , in both groups , the mean score of pruritus and the extent of lesions showed a greater reduction in women , and the differences in the mean total scorad index decreased more in men than in women . gender differences in mean scores of variables on in vitamin e - treated and placebo groups relapse rate , according to the scorad index , was determined 3 months after the intervention . from the total of 55 patients who remained in the study , the relapse rate was 25% ( 7/28 ) in the treatment group vs. 22.2% in the placebo group ( 6/21 ) than the placebo group with no significant differences between groups . this was a rct of low dose vitamin e single therapy for patients with ad . the results of this study suggest efficacy of vitamin e supplementation and improvement of some clinical symptoms in patients with ad . topical corticosteroids are usually a main component of treatment protocol for acute phase of ad . the most common complications of these medications are burning , itching , and dryness , which are due to a steroid carrier molecule . telangiectasia , purpura , stretch mark , and skin atrophy are some of their local complications . increased intraocular pressure , cataract , and glaucoma may result from long - term use of topical corticosteroids around the eyes . topical corticosteroids may be systemically absorbed and systemic side effects including suppression of hypothalamus - pituitary - adrenal axis are major concerns . human body can not produce this vitamin and the skin levels of vitamin e depend on its oral or topical use . a nutritional survey conducted on 10,000 people in us showed that most women and men do not get the recommended amount of vitamin e. isomeric form of alpha - tocopherol that is naturally found in foods , also called natural alpha - tocopherol ( rrr - alpha - tocopherol ) , is biologically active . the most important action of alpha - tocopherol in the body is its antioxidant property . furthermore , vitamin e is involved in activation of some molecules and enzymes in immune and inflammatory cells . vitamin e protects the macrophage membrane against oxidative damage and reduces production of prostaglandins through affecting the immune system . oxidative stress and altered antioxidant activity may be involved in acute exacerbations of ad in children . noh et al . found that serum ige levels could be a predictive factor for prognosis of dermatologic diseases and demonstrated that serum ige levels has declined significantly in patients treated with gamma interferon . studied 96 patients with ad and found a significant association between vitamin e and serum ige levels ; moreover , the clinical symptoms improved after treatment with vitamin e. few side effects have been reported in adults taking < 2,000 mg / day of alpha - tocopherol ; however , long - term side effects have not been studied . patients receiving anticoagulant or those with vitamin k deficiency have an increased risk for bleeding and should be under direct supervision of a physician for receiving vitamin e. although contact dermatitis , burning , and itching have been reported on topical use of vitamin e , none of them occurred in patients receiving vitamin d ( 400 iu / day ) of our study . low dose of vitamin e ( 400 iu / day ) can be effective in the treatment of ad patients with no side effects . however , larger well - designed double blind rcts are required before its integration in clinical guideline for treatment of ad . fj contributed in the conception of the work , analysis and interpretation of data for the work , drafting and critical revising the draft , approval of the final version of the manuscript , and agreed for all aspects of the work . gf contributed in the conception and design of the work , conducting the study , revising the draft , approval of the final version of the manuscript , and agreed for all aspects of the work . am contributed in the conception of the work , acquisition of data , drafting the work , approval of the final version of the manuscript , and agreed for all aspects of the work . smh contributed in the design of the work , analysis of data , revising the draft , approval of the final version of the manuscript , and agreed for all aspects of the work .
background : the pathogenesis of atopic dermatitis ( ad ) remains to be determined ; recently a possible change in the immune system with production of immunoglobulins is proposed . as vitamin e is a potent antioxidant , with the ability to decrease the serum levels of immunoglobulin e ( ige ) in atopic patients , we aimed to evaluate the effect of oral vitamin e on treatment of ad.materials and methods : this randomized , double - blind , placebo - controlled trial comprised seventy participants with mild - to - moderate ad , based on the hanifin and rajka diagnostic criteria 
 . the patients were randomly selected from teaching skin clinics in isfahan , iran . 
 they were randomly assigned to two groups of equal number , receiving vitamin e ( 400 iu / day ) and placebo for four 4 months . 
 each month , the extent , severity , and subjective symptoms including itch and sleeplessness were measured by scorad index . 
 three months after the end of intervention , the recurrence rate was assessed.results:the improvement in all symptoms , except sleeplessness , was significantly higher in the group receiving vitamin e than in controls ( 1.5 vs. 0.218 in itching , 10.85 vs. 3.54 in extent of lesion , and 11.12 vs. 3.89 in scorad index , respectively , p < 0.05 ) . 
 three months after the end of intervention , the recurrence rate of ad was evaluated . 
 recurrence rate between all 42 individuals , who remained in the study , was 18.6% . 
 recurrence ratio of the group receiving vitamin e compared to the placebo group was 1.17 , without significant differences between the two groups ( p > 0.05).conclusion : this study suggests that vitamin e can improve the symptoms and the quality of life in patients with ad . 
 as vitamin e has no side effects with a dosage of 400 iu / day , it can be recommended for the treatment of ad .