Skin surface lipids in HIV-positive patients with and without seborrheic dermatitis

An updated review of the sebaceous gland and its role in health and diseases Part 2: Pathophysiological clinical disorders of sebaceous glands

Sebaceous glands are sebum-secreting components of pilosebaceous units. In the second of this two-part series, we review the pathologies in which sebaceous glands are primarily and secondarily implicated. They are primarily involved in steatocystoma simplex and multiplex, sebaceous gland hyperplasia, sebaceoma, sebaceous adenoma, sebaceous carcinoma, nevus sebaceus, and folliculosebaceous cystic hamartoma. Sebaceous glands are secondarily involved in acne vulgaris, seborrheic dermatitis, and androgenic alopecia. Steatocystoma multiplex is a benign congenital anomaly presenting as yellow cysts primarily on the upper body. Sebaceous gland hyperplasia is characterized by yellow, telangiectatic papules with a central dell, and it can be treated with topical retinoids or surgical excision. Sebaceoma clinically presents on the head and neck region as a skin-colored nodule and can be distinguished by immunohistochemistry. Stains used in the diagnosis of sebaceous adenoma and carcinoma include epithelial membrane antigen and adipophilin immunoperoxidase. Surgical excision is the preferred treatment for sebaceoma, sebaceous adenoma, and sebaceous carcinoma. Excision is not always indicated for nevus sebaceus. Folliculosebaceous cystic hamartoma is a relatively rare condition exhibiting both epithelial and mesenchymal components. Patients with acne vulgaris commonly present with papules of closed and open comedones displaying hypercornification. Seborrheic dermatitis presents as sharply demarcated yellow or red patches or plaques; antifungal agents, corticosteroids, and combination antifungal/anti-inflammatory therapies are common treatment modalities. As a result of hair follicle miniaturization, females with androgenic alopecia present with diffuse hair thinning, while men tend to present with balding and hairline recession.

Prevalence of Malassezia species on the skin of HIV-seropositive patients

Malassezia is a genus of lipophilic yeasts residing on the skin of warm-blooded animals. The correlation between specific species and their involvement in skin diseases has been well researched. However, only very few studies have investigated the distribution of Malassezia spp. on the healthy skin of patients infected with human immunodeficiency virus (HIV). The purpose of this work was to analyze whether the composition of Malassezia spp. isolated from the skin of the HIV-infected patients differs from that of healthy individuals. The study included a total of 96 subjects, who were divided into two equally sized groups: HIV-seropositive and HIV-seronegative. The specimens were collected from the subjects by swabbing four anatomical sites (face, chest, back, and scalp). Species were identified using phenotype-based methods, and the identification of strains isolated from the HIV-seropositive patients was confirmed by PCR sequencing of the rDNA cluster. Malassezia spp. were isolated from 33 (69%) HIV-seropositive patients and 38 (79%) healthy volunteers. It was found that men were much more likely to have their heads colonized with Malassezia spp. than women. The most prevalent species on the skin of both HIV-seropositive and HIV-seronegative individuals were Malassezia sympodialis, M. globosa, and M. furfur, albeit at different proportions in the two populations. The diversity of Malassezia spp. was the highest on the face of the HIV-seropositive patients (Shannon-Weiner Index H = 1.35) and lowest on the back of the healthy volunteers (H = 0.16). The phenotype- and molecular-based identification methods were congruent at 94.9%. It was observed a tendency that the HIV-seropositive patients had higher CD4+ cell counts, indicating higher colonization with Malassezia spp.

Serum zinc levels in seborrheic dermatitis: a case-control study

Background/aim

Malassezia colonization, sebaceous gland activity, hormones, immune system defects, environmental factors, and the interactions between these factors are thought to contribute to the pathogenesis of seborrheic dermatitis (SD). Zinc, an essential element, is involved in many biological processes including the ones that contribute to the development of SD. The aim of this study is to evaluate serum zinc levels in patients with SD.

Materials and methods

Forty-three patients with SD and 41 healthy controls were enrolled in the study. Disease activity was assessed by the Seborrheic Dermatitis Area and Severity Index by a single dermatologist. Serum zinc levels of all subjects were evaluated.

Results

Statistically significantly lower serum zinc levels were noted in SD patients than in the control group (79.16 ± 12.17 vs. 84.88 ± 13.59, respectively; P = 0.045).

Conclusion

The results of the study demonstrated that patients who had SD had lower levels of serum zinc levels than healthy subjects.

Assessing Biophysical and Physiological Profiles of Scalp Seborrheic Dermatitis in the Thai Population

Background

Scalp seborrheic dermatitis (SD) is a common and chronic inflammatory skin disease which tends to recur over time. By measuring biophysical properties of the stratum corneum, many studies report abnormal biophysical profiles and their association in various dermatologic diseases. The aim of the study is to analyze the biophysical properties and skin barrier defects of scalp SD compared to healthy controls.

Materials and Methods

This study is a cross-sectional study assessing the correlation of various biophysical and physiological profiles in scalp SD. Forty-two Thai participants with scalp SD were enrolled in the study and 40 healthy participants were also enrolled as the control group. Both SD and control group were subjected to a one-time biophysical and physiological properties' measurement of transepidermal water loss (TEWL), stratum corneum hydration (SCH), skin surface pH, skin surface lipid, and skin roughness.

Results

The mean TEWL of lesional skin of SD cases were significantly higher than those of control group (P<0.05). Relating to high mean TEWL, the mean SCH was found to be significantly lower in SD cases (P<0.05). Skin surface lipid was also found to be significantly higher in SD group (P<0.05). However, there were no differences in skin surface pH (P=0.104) and roughness (P=0.308) between the two groups. Pairwise comparison of each subgroup found that moderate and severe SD demonstrated significantly higher mean skin surface lipid than that of control group (P<0.05).

Conclusion

Scalp SD may be associated with seborrhea in Thai population. Monitoring of SCH, TEWL, and skin surface lipid could be helpful in assessing severity and evaluating the treatment outcome in patients with scalp SD.

High Staphylococcus epidermidis Colonization and Impaired Permeability Barrier in Facial Seborrheic Dermatitis

BACKGROUND

Seborrheic dermatitis (SD) is a common inflammatory skin condition. The etiology is unclear, although overgrowth of Malassezia on the skin has been suggested to cause SD. This study investigated whether colonization with Staphylococcus plays a role in facial SD, which was not well addressed previously.

METHODS

The study was conducted from September 1, 2011 to February 20, 2012 in the First Hospital of China Medical University. In the first phase, the study evaluated the level of transepidermal water loss (TEWL) and the number of colony-forming units (CFU) of Staphylococcus in defined skin areas of SD patients who were human immunodeficiency virus (HIV) seropositive (HIV [+] SD [+] group, n = 13), classical SD (HIV [-] SD [+] group, n = 24) patients, HIV seropositive-non-SD (HIV [+] SD [-] group, n = 16) patients, and healthy volunteers (HIV [-] SD [-] group, n = 16). In the second phase, we enrolled another cohort of HIV (-) SD (+) patients who applied topical fusidic acid (n = 15), tacrolimus (n = 16), or moisturizer (n = 12). Changes in the Seborrheic Dermatitis Area Severity Index (SDASI), TEWL, and Staphylococcus density were evaluated 2 weeks later. Comparisons of each index were performed using analysis of variance (ANOVA) and least significant difference method.

RESULTS

The level of TEWL was greater through lesional sites in the HIV (+) SD (+) group than that in HIV (+) SD (-) and HIV (-) SD (-) groups (95% confidence interval [CI]: 18.873-47.071, P < 0.001 and 95% CI: 28.755-55.936, P < 0.001, respectively). The number of CFU of Staphylococcus was greater in the HIV (+) SD (+) group than that in HIV (+) SD (-) and HIV (-) SD (-) groups (95% CI: 37.487-142.744, P = 0.001 and 95% CI: 54.936-156.400, P < 0.001, respectively). TEWL was significantly more improved in patients treated with tacrolimus and fusidic acid than that in those treated with moisturizers (95% CI: 7.560-38.987, P = 0.004 and 95% CI: 4.659-37.619, P = 0.011, respectively). Topical tacrolimus and fusidic acid were significantly associated with decreased SDASI as compared with moisturizer (95% CI: 0.03-0.432, P = 0.025 and 95% CI: 0.033-0.44, P = 0.024, respectively).

CONCLUSIONS

High colonization with Staphylococcus epidermidis, along with impaired skin permeability barrier function, contributes to the occurrence of SD.

Seborrheic Dermatitis and Dandruff: A Comprehensive Review

Seborrheic Dermatitis (SD) and dandruff are of a continuous spectrum of the same disease that affects the seborrheic areas of the body. Dandruff is restricted to the scalp, and involves itchy, flaking skin without visible inflammation. SD can affect the scalp as well as other seborrheic areas, and involves itchy and flaking or scaling skin, inflammation and pruritus. Various intrinsic and environmental factors, such as sebaceous secretions, skin surface fungal colonization, individual susceptibility, and interactions between these factors, all contribute to the pathogenesis of SD and dandruff. In this review, we summarize the current knowledge on SD and dandruff, including epidemiology, burden of disease, clinical presentations and diagnosis, treatment, genetic studies in humans and animal models, and predisposing factors. Genetic and biochemical studies and investigations in animal models provide further insight on the pathophysiology and strategies for better treatment.

Efficacy of Oral Itraconazole in the Treatment and Relapse Prevention of Moderate to Severe Seborrheic Dermatitis: A Randomized, Placebo-Controlled Trial

BACKGROUND

Seborrheic dermatitis (SD) is a chronic and relapsing disease and topical therapy may be associated with failure, particularly in severe disease. Itraconazole has been suggested as an effective treatment for severe SD. Previous studies have been open clinical trials with variable results.

OBJECTIVE

The aim of this study was to determine the efficacy of oral itraconazole in the treatment of patients with moderate to severe SD.

METHODS

Sixty-eight patients with moderate to severe SD were randomly assigned to the itraconazole (n = 35) or placebo (n = 33) groups. The trial was undertaken in Razi Hospital, Tehran. An internet-generated table was used to allocate treatments. Patients and investigator were blinded to treatments. Itraconazole 200 mg/daily or placebo was prescribed for 1 week and then for the first 2 days of every month for the following 3 months. Patients were followed for 4 months and the Seborrheic Dermatitis Area Severity Index (SDASI) was measured on nine anatomical sites. Fifty-seven patients (29 in the itraconazole group and 28 in the placebo group) completed the study.

RESULTS

Statistically significant improvement was observed in SDASI of both itraconazole and placebo groups (p = 0.000) but the itraconazole group showed significantly higher efficacy compared with placebo (p = 0.023). We observed clinical improvements of 93.8, 87.5, and 93.1% at the end of 2 weeks, 1 month, and 4 months, respectively, in the itraconazole group, and 82.1, 64.3, and 53.6% in the placebo group. Furthermore, recurrence rate in the itraconazole group was significantly lower than in the placebo group (p = 0.003). No blood test abnormality was seen in any patient.

CONCLUSION

Itraconazole is not only an effective and safe therapy for controlling exacerbations of SD but may also be used as maintenance therapy to prevent disease recurrence.

Seborrheic dermatitis

Seborrheic dermatitis is a common inflammation of the skin, occurring most often on the face, scalp and chest. It is closely related to infantile seborrheic dermatitis, or diaper rash. Seborrheic dermatitis is particularly common in patients with Parkinson's disease or with HIV/AIDS. The recent resurgence of interest in Malassezia yeasts has revived the old hypothesis that seborrheic dermatitis is caused by an altered relationship between these skin commensals and the host. Moreover, the success of antifungal medications in treating seborrheic dermatitis provides new evidence for this view.

LEARNING OBJECTIVE

Upon completing this paper, the reader should be aware of the clinical presentation of seborrheic dermatitis and which populations are at particular risk of developing this disorder. In addition, s/he will be aware of the role of Malassezia yeasts in seborrheic dermatitis and the way in which knowledge of the importance of these yeasts has altered the treatment of this disorder.

A retrospective survey of mucocutaneous manifestations of HIV infection in Malaysia: analysis of 182 cases

A retrospective analysis of 182 HIV positive Malaysians was done in two centers, the University Hospital Kuala Lumpur (UHKL) and the General Hospital Kuala Lumpur (GHKL) from March 1997 to February 1998. Demographic and clinical data were analyzed. The analysis showed that 130 out of 182 patients had mucocutaneous disorders (71.4%). In the study there were 125 males (96.2%) and 5 females (3.8%). The majority of the patients were in the age group from 20 to 50 years. The patients who presented with mucocutaneous disease also had low CD4+ T lymphocyte counts, and most of them had AIDS defining illnesses. The number of cases with generalized hyperpigmentation was very high (35.7%), followed by papular eruptions (29.1%) and xerosis (27.5%). Seborrheic dermatitis was seen in 19.2% of the cases and psoriasis in 7.7%. The most common infections were oral candida 35.7%, tinea corporis and onychomycosis 9.9%, and herpes infection 4.3%. However, mucocutaneous manifestations of Kaposi's sarcoma were rare. The results suggested that mucocutaneous findings are useful clinical predictors of HIV infection or a sign of the presence of advanced HIV infection.

Mucocutaneous manifestations of HIV infection: a retrospective analysis of 145 cases in a Chinese population in Malaysia

BACKGROUND

Mucocutaneous lesions directly related to human immunodeficiency virus (HIV) infection usually present as initial manifestations of immune deficiency. The most common mucocutaneous lesions are Kaposi's sarcoma, histoplasmosis, oro-esophageal candidiasis, oral hairy leukoplakia, and, in Asia, Penicillium marneffei infection. Non-HIV-related skin lesions, such as psoriasis, seborrheic dermatitis, and nodular prurigo, may be the initial presentation among HIV infected patients attending outpatient clinics.

METHODS

A retrospective analysis was performed on 145 HIV-positive Malaysians of Chinese descent from two centers at the University Hospital Kuala Lumpur (UHKL) and the General Hospital Kuala Lumpur (GHKL) from March 1997 to February 1998. Demographic data and clinical data were analyzed.

RESULTS

The analysis showed that 104 out of 145 patients had mucocutaneous disorders (71.7%). In the study, there were 100 men (96.2%) and four women (3.8%). The majority of patients were in the age group 20-50 years. The patients who presented with mucocutaneous disease also had low CD4+ T-lymphocyte counts and most had acquired immunodeficiency syndrome (AIDS) defining illness. The number of cases with generalized hyperpigmentation was very high in the group (35.9%), followed by nodular prurigo (29.7%) and xerosis (27.6%). Seborrheic dermatitis was seen in 20.7% of cases, with psoriasis in 8.3%. The most common infections were oral candidiasis (35.9%), tinea corporis and onychomycosis (9.7%), and herpes infection (5.5%); however, mucocutaneous manifestations of Kaposi's sarcoma were rare.

CONCLUSIONS

The results suggest that mucocutaneous findings are useful clinical predictors of HIV infection or signs of the presence of advanced HIV infection.