Annarosa Virgili

Fungal Skin Infections in Organ Transplant Recipients

Transplantation is now currently and increasingly performed for the treatment of various acute and chronic diseases. Today the kidney, heart, lung, heart-lung, liver, pancreas, kidney-pancreas, small bowel and bone marrow are being transplanted. The immunological status of patients receiving such transplants exposes them to the risk of developing bacterial, viral and fungal infections.The etiological agents of mycotic diseases involving the skin of transplant recipients range from the common dermatophytes through yeasts such as Candida spp., Malassezia spp. and dimorphic fungi to the emerging molds Fusarium spp. and Pseudallescheria boydii.The very wide spectrum of fungi causing cutaneous disease produces equally varied clinical aspects. Lesions may be typical, but are very often aspecific or ambiguous.Cutaneous lesions may be the sign of a trivial mycotic disease or the marker of a disseminated, potentially lethal fungal illness, so great attention should be given to their early recognition.Cutaneous manifestations due to Candida spp., Aspergillus spp., dematiaceous fungi and Pityrosporum folliculitis are usually observed early after transplant, cryptococcosis more than 6 months later, while the frequency of dermatophytoses increases as time goes by. Coccidioides immitis, Histoplasma capsulatum and Blastomyces dermatitidis may appear any time after transplantation.The management of the more severe forms of cutaneous mycosis in transplant recipients is difficult. Besides the fact that early recognition is not easy, there are also problems regarding the effectiveness and the toxicity of the therapy and drug-drug interactions.Prophylactic measures to avoid fungal contamination must be performed during hospitalization; patients should be taught how to avoid contamination, not only during the first period after transplantation, when high dosage immunosuppressive drugs are given, but also later when a normal lifestyle is resumed.

Prevalence of Superficial Dermatomycoses in 73 Renal Transplant Recipients

Background: Because of chronic immunosuppressive therapy, the skin of renal transplant recipients (RTR) is considered more liable to fungal infections. Aim: The aim of the study was to analyze the prevalence of superficial dermatomycoses in a chronically immunosuppressed group of RTR who live in northern Italy and to verify the eventual relationship between the onset of mycoses, the immunosuppressive regimen and the interval of time elapsed after the transplantation. Methods: 73 RTR were submitted to a complete dermatological examination for fungal infection. Skin scrapings were taken from the upper back, from the 4th toe web of all patients and from any suspicious lesion. Results: 31 patients (42.5%) were affected by dermatomycosis. Pityriasis versicolor (PV) was present in 20 RTR (27.4%), fungal infection of the 4th toe web in 10 patients (13.7%) and onychomycosis in 9 RTR (12.3%). Trichophyton mentagrophytes was the most common dermatophyte. The prevalence of dermatomycoses was higher in the group of patients treated with azathioprine-cyclosporine-steroids and in those who had received their renal transplant in the previous 1–5 years. Conclusions: PV was the most frequent dermatomycosis and showed a higher prevalence than in the normal population. The prevalence of fungal infection of the 4th toe web and onychomycosis was similar to that found in the immunocompetent population, but the length of interval after transplantation seemed to increase the probability of their occurrence and of mixed or simultaneous fungal infections in the same patient.

Oral clindamycin and rifampicin in the treatment of hidradenitis suppurativa‐acne inversa: a prospective study on 23 patients

Editor Hidradenitis Suppurativa-Acne Inversa (HS-AI) is a relapsing and chronic inflammatory skin disease affecting the big folds. HS-AI is currently thought of as being an inflammatory and not an infectious disease, but sometimes various bacteria combined in polymicrobial infections can be present. Coagulasenegative staphylococcus and anaerobic bacteria are the most frequently isolated. The bacteria are suspected of playing a role in the disease process, probably through immune-mediated mechanisms of inflammation. Therapy of HS-AI is often difficult. Medical, surgical and physical therapeutical options are available. Although antibiotics are widely used to treat HS-AI limited data on their efficacy are available. To assess the efficacy and the tolerability of a 10-week combination of oral clindamycin (600 mg daily) and rifampicin (600 mg daily) in the treatment of HS-AI, 23 patients affected by severe and actively inflammatory HS-AI were enrolled in a prospective non comparative study. The ethical committee considered as not needed its official consensus to precede. No restrictions about previous treatments were established. The parameters used to evaluate the efficacy of the treatment were as follows: (i) severity of the disease, assessed with the Sartorius score before (T0) and after (T1) treatment and (ii) the number of exacerbations during the treatment period compared with those occurring in the previous three months. The authors considered as exacerbation the acute development of at least one wide inflammatory lesion. Finally, patients were asked about side-effects during treatment. Statistical analysis was performed using parametric test (t-test). Significance was accepted at P < 0.05. The main clinical-demographic data, collected in a standardized form, are summarized in Table 1. Three patients did not complete the treatment: one for personal reasons, one because of gastro-intestinal side-effects not related to Clostridium difficile colitis, and one, affected by amyotrophic lateral sclerosis, complained of a worsening of the neurological disease, probably not related to antibiotic assumption. The 20 patients who completed the 10-week therapy showed a mean Sartorius score of 132.05 (range 28.00–298.05) at T0 and 71.50 (range 19.50–183.00) at T1 corresponding to a mean reduction of 45.85% (range 5.41–81.95%). The authors considered as responders the 17 patients who achieved a Sartorius score improvement higher than 25%, corresponding to the 85% of the patients who completed the treatment. The mean number of exacerbations was 6.00 (range 1.00–20.00) at T0 and 2.40 (range 0–10.00) at T1 corresponding to a mean reduction of 60% (range 0–100%). Both Sartorius score and the number of exacerbations showed a significant reduction after treatment: P = 0.00098 for Sartorius score and P = 0.0091 for the number of exacerbations, respectively. Three out of 23 patients (13.04%) complained of side-effects, mostly nausea and vomiting: one patient stopped the therapy before the scheduled end, whereas the two remaining completed the 10-week treatment. The efficacy and tolerability of this combination treatment in HS-AI has previously been assessed in three retrospective studies. The present one is the first prospective study and the results are in agreement with those reported in literature (Table 2). The reason why this antibiotic combination is effective is not fully understood yet. This study has some limitations. The patients were not randomized vs. placebo or other treatments. This decision was made for ethical reasons and because, in the authors’ experience, this treatment is the best option in severe HS-AI in terms of efficacy, tolerability, quick onset of action and cost. No data about long-term follow-up and recurrences are given because a maintenance treatment with oral zinc was prescribed, according to the desire of the patients to do as much as possible to maintain the results they had obtained.

Proactive maintenance therapy with a topical corticosteroid for vulvar lichen sclerosus: preliminary results of a randomized study.

The chronic and relapsing nature of vulvar lichen sclerosus (VLS) represents a challenge for its long‐term management after an effective treatment with topical corticosteroids.

Use of topical herbal remedies and cosmetics: a questionnaire-based investigation in dermatology out-patients.

Background Although topical remedies and cosmetics based on herbal ingredients are becoming increasingly popular with the public due to the perception that botanical compounds are safer and healthier than their synthetic counterparts, a large number of adverse cutaneous effects of plant extracts, notably contact sensitization, have been reported in medical literature.

First randomized trial on clobetasol propionate and mometasone furoate in the treatment of vulvar lichen sclerosus: results of efficacy and tolerability

A 3‐month topical application of clobetasol propionate (CP) represents the recommended and accepted first‐line treatment for vulvar lichen sclerosus (VLS); however, to date, no randomized controlled trials have compared the efficacy and safety of CP with other topical corticosteroids.

Inverse Association Between Dietary Vitamin D and Risk of Cutaneous Melanoma in a Northern Italy Population

The possibility of an inverse association between vitamin D and risk of cancer and, in particular, of cutaneous malignant melanoma has been suggested, but results of epidemiologic studies are still conflicting. We examined the relation between dietary vitamin D intake and melanoma risk through a population-based case-control study (380 cases, 719 controls) in a northern region of Italy, a country with an average vitamin D intake lower than that in northern Europe or the United States. We assessed average daily intake of vitamin D from foodstuffs using the European Prospective Investigation into Cancer and Nutrition (EPIC) semiquantitative food frequency questionnaire. In this population, levels of vitamin D intake were considerably lower than those observed in recent U.S. studies. We found an inverse relation between dietary vitamin D and melanoma risk in the sample as a whole, in both crude and adjusted analyses. In sex- and age-specific analyses, this association appeared to be stronger among males and among older subjects. These findings suggest that, at the relatively low levels of intake observed in this sample, an inverse relation between dietary vitamin D and risk of cutaneous malignant melanoma may exist.

Surfactants, skin cleansing protagonists

The correct choice of cosmetic products and cleansers is very important to improve skin hydration, to provide moisturizing benefits and to minimize cutaneous damage caused by surfactants. In fact, surfactants may damage protein structures and solubilize lipids. Soaps, defined as the alkali salts of fatty acids, are the oldest surfactants and are quite aggressive. Syndets (synthetic detergents) vary in composition and surfactant types (anionic, cationic, amphotheric, non‐ionic). These new skin cleansing products also contain preservatives, fragrances, and sometimes emollients, humectants and skin nutrients. We present a revision of the literature and discuss recent findings regarding skin cleansers.

Vulvar lichen sclerosus: 11 women treated with tacrolimus 0.1% ointment.

Lichen sclerosus is a chronic relapsing disease, usually treated with ultra-potent corticosteroids. As immunological alterations are considered important aetiopathogenetic factors in lichen sclerosus, the new immunomodulating topical agents, such as tacrolimus and pimecrolimus, have been employed sporadically as alternative therapies. The aim of this study was to evaluate the therapeutic effects of tacrolimus 0.1% ointment in lichen sclerosus in 11 patients unresponsive or poorly responsive to previous treatments. Tacrolimus 0.1% ointment was applied twice daily for 6 weeks, then tapered over a further 6 weeks. Symptoms and objective parameters were evaluated and quantified at the start, after 6 weeks, at the end of the topical treatment, and at follow-up visits. Improvement or remission of symptoms was observed in the patients who completed the study, while objective parameters were poorly influenced and often were not related to symptom behaviour. Topical tacrolimus can be considered an alternative treatment for lichen sclerosus.

Melanoma epidemic across the millennium: time trends of cutaneous melanoma in Emilia-Romagna (Italy) from 1997 to 2004

Background  After a rapid increase in malignant melanoma (MM) incidence in the last decades, trends of the melanoma epidemic in the recent years seemed not homogeneous.