George Larios

Evaluation of the efficacy and safety of infliximab on psoriatic nails: an unblinded, nonrandomized, open‐label study

Background  Despite advances in the treatment of skin psoriasis during the last years, therapy of psoriatic nails remains a challenge.

The role of isotretinoin in acne therapy: why not as first-line therapy? facts and controversies

Acne is one of the most prevalent diseases in dermatology: Millions of people worldwide experience this distressing condition. To determine the appropriate therapeutic strategy, there is a strong need for a standardized classification system of acne. The exact molecular mechanism of action of isotretinoin is not completely understood; however, oral isotretinoin targets simultaneously at all major mechanisms of acne pathogenesis. Various mass media reports about the risk of teratogenicity and depression from isotretinoin usage as well as the creation of intense prevention programs have created an obstacle to the use of the most active available drug against acne, presenting isotretinoin as a very dangerous regimen. According to recommendations of several international experts, which we share, oral isotretinoin may be prescribed not only to patients with severe disease but indications should be broadened to also include patients with less severe forms of acne, especially in cases with scarring, significant psychologic stress, or failure to respond to conventional therapy.

Global epidemiology of cutaneous zygomycosis

The large majority of cases reported worldwide as zygomycosis are infections caused by fungi belonging to the order Mucorales. These infections are invasive, often lethal, and they primarily affect immunocompromised patients. Cutaneous zygomycosis is the third most common clinical presentation, after sinusitis and pulmonary disease. Most patients with cutaneous zygomycosis have underlying diseases, such as hematological malignancies and diabetes mellitus, or have received solid organ transplantation, but a large proportion of these patients are immunocompetent. Trauma is an important mode of acquiring the disease. The disease can be very invasive locally and penetrate from the cutaneous and subcutaneous tissues into the adjacent fat, muscle, fascia, and bone. The diagnosis of cutaneous zygomycosis is often difficult because of the nonspecific findings of the infection. The clinician must have a high degree of suspicion and use all available diagnostic tools, because early diagnosis leads to an improved outcome. The treatment of zygomycosis is multimodal and consists of surgical debridement, use of antifungal drugs, and reversal of underlying risk factors, when possible. The main antifungal drug used in the treatment of zygomycosis is amphotericin B. Posaconazole is sometimes used for salvage treatment, as continuation of treatment after initial administration of amphotericin B, or in combination. The mortality of cutaneous zygomycosis is lower in comparison with other forms of the disease, but it is still significant. When the disease is localized, mortality still ranges from 4% to 10%.

Treatment of Nail Psoriasis with a Two-Compound Formulation of Calcipotriol plus Betamethasone Dipropionate Ointment

Background: Treatment of nail psoriasis remains a challenge. Objective: To evaluate the efficacy of a two-compound product of calcipotriol plus betamethasone dipropionate ointment on nail psoriasis in an open-label study. Methods: Twenty-five psoriatic patients with nail involvement and mild cutaneous psoriasis were instructed to apply a calcipotriol-betamethasone valerate ointment formulation once daily for 12 weeks on affected nails. Outcome measures were assessed at baseline and at weeks 4, 8 and 12 using the nail psoriasis severity index (NAPSI). Results: Twenty-two patients having 114 nails involved at baseline with a mean NAPSI of 5.8 ± 1.7 were followed up for 12 weeks. The mean NAPSI at the end of the treatment period was reduced to 1.6 ± 0.6 presenting a 72% improvement. Significant improvement was observed for hyperkeratosis and onycholysis (reduction of mean hyperkeratosis NAPSI from 2.2 ± 0.5 to 0.5 ± 0.1 and mean onycholysis NAPSI from 2.0 ± 0.6 to 0.4 ± 0.2), moderate improvement for oil drops (reduction of mean oil drop NAPSI from 1.2 ± 0.4 to 0.8 ± 0.3) and slight improvement for pitting (reduction of mean pitting NAPSI from 0.8 ± 0.2 to 0.6 ± 0.2). Conclusions: The calcipotriol plus betamethasone dipropionate two-compound ointment, applied once daily for 12 weeks, was shown to improve nail psoriasis.

Efficacy and safety of tacrolimus ointment 0·1% vs. betamethasone 17‐valerate 0·1% in the treatment of chronic paronychia: an unblinded randomized study

Background  Recent studies have established the pivotal role of irritants and allergens in development of chronic paronychia and the significant improvement with corticosteroid therapy.

Skin signs of systemic diseases.

The skin should not be considered as an isolated organ but rather as a definite functioning system that communicates with the internal environment. Skin signs of systemic diseases occur frequently and sometimes feature the first symptoms of an internal disease; furthermore, these manifestations may be the sole expressions of otherwise asymptomatic systemic disorders. A number of dermatologic signs, symptoms, and disorders can be invaluable as markers of systemic disease. Although a plethora of specialized modern diagnostic tests are available, the skin still remains the only organ of the body that is immediately and completely accessible to direct clinical examination. This contribution reviews the skin signs of systemic diseases. The description of the clinical features of skin lesions observed in several internal diseases will be useful to general physicians, internists, and dermatologists in the diagnosis of a systemic disease.

Treatment of Pseudomonas nail infections with 0.1% octenidine dihydrochloride solution.

The beginning of the treatment was preceded by a 30-day washout period in subjects using topical or systemic antimicrobials. The patients were evaluated after 6 weeks of application of 0.1% octenidine dihydrochloride solution with microscopy and culture. Patients having both negative microscopy and culture results were considered as cured regardless of nail coloring, since the nail hue has been suggested to result from diffusion of pyocyanin rather than the true invasion of Pseudomonas in nail plate [1] . Ten patients reported that their hands were frequently immersed in water; the other 4 had diabetes or another nail disease and only 1 patient (No. 3) presented the Pseudomonas nail infection without any predisposing factors. At the end of the 6th week of application of 0.1% octenidine dihydrochloride solution, 12 of 15 patients (80%) had complete clearance of their affected nails ( fig. 2 ). Three female patients (No. 2, 11 and 14) failed to respond, probably due to their occupations. No adverse effects were noticed during the application period. Pseudomonas are gram-negative waterborne rod bacteria. The pathogenesis of nail infection by Pseudomonas remains obscure. It is considered to be a complication of onycholysis of various origin or chronic paronychia [2] , and this is confirmed in our series ( table 1 ). It also seems that a paronychial infection with Pseudomonas is usually preceded by onycholysis or paronychia, leading to pyocyanin pigment staining of the adjacent nail [1] . The disease commonly is restricted to 1 or 2 nails. Pseudomonas is usually isolated on cultures of specimens taken from the paronychia. Topical treatment includes removal of the onycholytic portion of the nail and avoidance of wetness [3] , brushing of the nail bed with a 2% sodium hypochlorite solution twice daily [1] , application of diluted acetic acid or polymyxin B 2 and vinegar soaks (10-parts water and 1-part white vinegar) for 5–10 min twice daily for 5 days [4] . Octenidine dihydrochloride is a well-known topical antibacterial agent active. Octenidine has been shown to possess microbicidal activity against Staphylococcus aureus , Staphylococcus epi

Efficacy and safety of tacrolimus ointment 0·1% vs. betamethasone 17-valerate 0·1% in the treatment of chronic paronychia: an unblinded randomized study. Reply from authors

MADAM, We discussed in our Journal club the paper by Rigopoulos et al., ‘Efficacy and safety of tacrolimus ointment 0Æ1% vs. betamethasone 17-valerate 0Æ1% in the treatment of chronic paronychia: an unblinded randomized study’. We are concerned that the conclusions stated in the summary cannot be justified by the results and that the title and abstract are potentially misleading. The study compares three equal-sized groups in terms of subjective clinical response to topical application of 0Æ1% tacrolimus ointment, 0Æ1% betamethasone 17-valerate ointment and emollient ‘placebo’ Bepanthol cream. Significant differences are reported between both active agents and emollient ‘placebo’ but not between active agents. Yet the authors claim that topical tacrolimus appears to be more efficacious than steroid. Secondly, the authors acknowledge in their discussion that the ointment formulation of tacrolimus might contribute to therapeutic efficacy. Yet they ‘controlled’ their study with a cream. The control ⁄placebo needed to be the ointment vehicle common to the active agents. We believe usage of different vehicle-based applications calls into question the credibility of the findings. Thirdly, although subjective clinical criteria have been outlined 6 weeks into the trial to gauge therapeutic response, no similar grading was applied at the onset of treatment: severity could have an influence on clinical outcome. Next we are told that positive mycology was an exclusion criterion. Yet ‘the presence of fungi is frequent in patients with chronic paronychia’ (the authors’ quote). This exclusion is not obvious in the title or abstract. Furthermore, bacterial infection has not been considered to be an exclusion or inclusion criterion and the role of bacteria in the aetiology of chronic paronychia is not discussed. Finally, no systemic contraindications or exclusion factors have been taken into account other than diabetes mellitus. In summary, we feel that the work and how it has been reported and published are flawed.

Rosacea-like demodicidosis

A 64-year-old woman presented with multiple asymptomatic, erythematosus papulopustular facial lesions (fi gure, A). The patient had been diagnosed with rosacea, and received oral doxycycline, 100 mg twice daily for 3 weeks as fi rst-line therapy by her family doctor. Because of the poor response to therapy, she had been referred to our dermatology clinic for further evaluation. On clinical examination, the eruptions, which were practically asymptomatic, had a rosacea-like appearance. They had emerged and gradually worsened over a period of 5 weeks. There were no pathological fi ndings on physical examination and routine laboratory test results were normal. Microscopic examination of specimens collected from the patient’s skin by epidermal scraping showed many Demodex folliculorum mites (fi gure, B, magnifi cation ×100). The patient showed substantial improvement after treatment with oral metronidazole (250 mg three times daily for 2 weeks) and subsequent weekly topical permethrin (cream 5%). Demodex spp are common saprophytic vermiform mites, which asymptomatically parasitise the hair follicles and the pilosebaceous glands of mammals. In human beings, two species of acarid mite have been identifi ed: Demodex folliculorum and Demodex brevis. Sites favoured by Demodex spp mites include the scalp, forehead, and chin, and areas around the orbit, nose, and mouth. Demodex spp have been implicated in the development of various facial conditions, including pityriasis folliculorum, rosacea-like demodicidosis (also known as demodicosis), pustular folliculitis, demodectic blepharitis, and so-called “demodicidosis gravis”. Clinical features of Demodex spp infestation include erythematopapulous and pustulous skin lesions together with erythematodesquamative changes of the face. Furthermore, demodicidosis should also be considered in any patient with rosacea-like dermatitis resistant to conventional rosacea therapies. Although there is no consensus to how and what degree infestation with Demodex spp mites contributes to skin pathology, there is evidence that demodicidosis is a condition distinct from common rosacea. The prevalence of Demodex spp carriers increases with age. It is possible that large numbers of demodex mites can stimulate infl ammatory or allergic reactions by mechanical blockage of follicles, or by acting as vectors for microorganisms, which ultimately results in connective tissue damage and telangiectasia. Another interesting hypothesis is that infl ammatory response may be stimulated by antigenic proteins related to a bacterium (Bacillus oleronius) isolated from D folliculorum.

Letter: Further Options for Treatment of Hypertrophic Scars and Keloids

The article, ‘‘Hypertrophic Scars and KeloidsFA Review of Their Pathophysiology, Risk Factors, and Therapeutic Management,’’ by Wolfram and colleagues in the February 2009 issue of Dermatologic Surgery is a comprehensive review of the pathophysiology of hypertrophic scars (HSs) and keloids, illustrating useful recommendations for their therapeutic management, but from the dermatologists’ point of view, we would like to suggest further options for treatment that are not included in the aforementioned review article.