Report of terbinafine resistant Trichophyton spp. in Italy: Clinical presentations, molecular identification, antifungal susceptibility testing and mutations in the squalene epoxidase gene

BACKGROUND

Numerous reports of resistance to terbinafine in Trichophyton spp. from all over the world are arousing justified attention and concern. Point mutations in the gene that encodes the squalene epoxidase (SQLE) enzyme are responsible for these therapeutic resistances.

OBJECTIVES

Primary objective of the study was to describe first isolates of Trichophyton spp. resistant to terbinafine among the patients treated between September 2019 and June 2022 at the Dermatology Units of Ospedale Maggiore Policlinico and San Bortolo Hospital. Secondary objective was to study the resistance mechanism.

METHODS

Patients with confirmed Trichophyton spp. infection has been treated with systemic and topical terbinafine. Patients were then re-evaluated 12 weeks after the therapy. Patients with incomplete or absent response to terbinafine underwent a new skin scraping for direct mycological examination, new identification of dermatophyte species from culture and MALDI-TOF, molecular species identification, antifungal susceptibility testing and molecular analysis of SQLE gene.

RESULTS

We identified five patients without clinical response to treatment with terbinafine. The DNA sequencing of the ITS region identified one Trichophyton rubrum and four Trichophyton indotineae. The T. rubrum strain showed minimum inhibitory concentration (MIC) (90% growth inhibition) of 4 mg/L for terbinafine. The four T. indotineae strains showed a MICs range of 0.25-4 mg/L for terbinafine. The analysis of the SQLE gene in the T. rubrum strain showed a nucleotide substitution generating a missense mutation (L393F). The SQLE gene sequencing in the T. indotineae strains showed a nucleotide substitution generating a missense mutation (F397L) in two strains, a nucleotide substitution L393S in one strain and a nucleotide substitution F415C in another strain.

CONCLUSIONS

We report the first cases of terbinafine-resistant Trichophyton isolates in the Italian population. Solid antifungal management programs will be needed to promote more responsible use of antimycotics and preserve their therapeutic efficacy to control antifungal resistance.

The patient journey: a voyage from diagnosis to hidradenitis suppurativa multidisciplinary unit

BACKGROUND

Hidradenitis suppurativa (HS) is an inflammatory, recurrent and debilitating chronic skin disease that is often worsened by comorbidities, with a destructive impact on the social and working life of the patient. The low awareness of patients and clinicians regarding HS, together with weak coordination between specialists who manage the clinical care of these patients, may result in a burdening diagnostic and therapeutic delay, lowering efficacy of therapies and worsening prognosis and patients' QoL.

OBJECTIVES

To rule out these critical aspects, a HS-Multidisciplinary Unit with a hierarchical organization is proposed.

METHODS

Based on previously published models of a multidisciplinary unit, a hierarchical structure of a HS-dedicated multidisciplinary unit was designed.

RESULTS

In this model, an operational core constituted by four healthcare professionals constantly working as team, is supported by a large panel of consultants, local dermatologists and general practitioners, helping in HS patient management.

CONCLUSIONS

This standardization would imply an optimization of professional resources, an amelioration of patient's quality of life, and a shortening of patient journey.

Rosacea fulminans: two case reports and review of the literature

Rosacea fulminans is a rare and severe inflammatory dermatosis which affects predominantly childbearing women. It is characterized by sudden onset and it usually localizes exclusively on the centrofacial areas, presenting with numerous fluctuant inflammatory nodules and papules which may coalesce. Treatment with isotretinoin in combination with topical and systemic corticosteroids is successful. Clearance of lesions may be obtained under systemic treatment with no or minimal scarring outcomes. Due to rare incidence its pathophysiological mechanisms, diagnosis and management remain controversial. We report two cases of rosacea fulminans arisen in otherwise healthy people and completely healed after treatment. Our aim is to share our experience about this disease in order to increase knowledge about its diagnosis, management and its treatment. We also make a review of the literature of this peculiar dermatosis.

Cutibacterium acnes (Propionibacterium acnes) and acne vulgaris: a brief look at the latest updates

While the commensal bacterium Propionibacterium acnes (P. acnes) is involved in the maintenance of a healthy skin, it can also act as an opportunistic pathogen in acne vulgaris. The latest findings on P. acnes shed light on the critical role of a tight equilibrium between members of its phylotypes and within the skin microbiota in the development of this skin disease. Indeed, contrary to what was previously thought, proliferation of P. acnes is not the trigger of acne as patients with acne do not harbour more P. acnes in follicles than normal individuals. Instead, the loss of the skin microbial diversity together with the activation of the innate immunity might lead to this chronic inflammatory condition. This review provides results of the most recent biochemical and genomic investigations that led to the new taxonomic classification of P. acnes renamed Cutibacterium acnes (C. acnes), and to the better characterisation of its phylogenetic cluster groups. Moreover, the latest data on the role of C. acnes and its different phylotypes in acne are presented, providing an overview of the factors that could participate in the virulence and in the antimicrobial resistance of acne-associated strains. Overall, this emerging key information offers new perspectives in the treatment of acne, with future innovative strategies focusing on C. acnes biofilms and/or on its acne-associated phylotypes.

HIV, cutaneous larva migrans and fever

The authors describe two cases of cutaneous larva migrans associated with fever in two HIV-positive patients. Laboratory and instrumental examinations allowed to exclusion of other possible causes of fever. The presence of fever in patients with cutaneous larva migrans might represent a marker of HIV infection.

Purpuric herpes zoster in patients in therapy with clopidogrel

Clopidogrel is an adenosine diphosphate receptor antagonist used for the prevention of vascular events in patients with atherothrombotic diseases manifested by recent myocardial infarction, ischemic stroke or peripheral arterial disease. Diarrhoea, rash and pruritus are rather common side effects of clopidogrel. Other side effects include epistaxis, nausea, abdominal pain, vomiting, gastritis, gastric and duodenal ulcer. Thrombocytopenia is the most common laboratory abnormality. Leucopenia and neutropenia are rare. We report three cases of purpuric herpes zoster in patients in therapy with clopidogrel. To our knowledge, only one case of haemorrhagic herpes zoster has been published in a patient in therapy with this drug.

Treatment of mild to moderate acne with a fixed combination of hydroxypinacolone retinoate, retinol glycospheres and papain glycospheres

AIM

A fixed combination of 0.1% hydroxypinacolone retinoate (synthetic esther of 9-cis-retinoic acid), 1% retinol in glycospheres and 2% papain in glycospheres in aqueous gel has been recently introduced into the Italian market in order to reduce the incidence and severity of irritant contact dermatitis caused by topical retinoids, without compromising their efficacy. Primary objectives of this sponsor-free, pilot, open, multicenter study were to evaluate the efficacy and tolerability of this gel in patients with comedonal-papular, mild to moderate acne of the face.

METHODS

Ninety-eight Caucasian patients (28 males and 70 females), with an age ranging from 15 to 40 years, were treated with the gel once daily for 12 weeks. Acne severity and treatment efficacy were evaluated by means of the Global Acne Grading System (GAGS) and lesions count.

RESULTS

Ninety-four patients were considered evaluable. A 41% mean reduction in the GAGS score was observed; a 40.8% mean reduction of total lesions was recorded; 15.3% of patients experienced mild to moderate local side effects (dryness, peeling, erythema, burning). No patients stopped the treatment because of these side effects.

CONCLUSION

This study, based on a high number of evaluable patients, demonstrates that this fixed combination is an effective and safe option for the treatment of comedonal-papular, mild to moderate acne of the face. A controlled clinical study is necessary to confirm these data.

Dermatomycoses and inflammation: The adaptive balance between growth, damage, and survival

Dermatomycosis is characterized by both superficial and subcutaneous infections of keratinous tissues and mucous membranes caused by a variety of fungal agents, the two most common classes being dermatophytes and yeasts. Overall, the stepwise process of host infection is similar among the main dermatomycotic species; however, the species-specific ability to elicit a host reaction upon infection is distinct. Yeasts such as Candida albicans elicit a relatively low level of host tissue damage and inflammation during pathogenic infection, while dermatophytes may induce a higher level of tissue damage and inflammatory reaction. Both pathogens can, however, manipulate the host's immune response, ensuring survival and prolonging chronic infection. One common element of most dermatomycotic infections is the disease burden caused by inflammation and associated signs and symptoms, such as erythema, burning and pruritus. There is a strong clinical rationale for the addition of a topical corticosteroid agent to an effective antimycotic therapy, especially in patients who present with inflammatory dermatomycoses (e.g., tinea inguinalis). In this review, we aim to compare the pathogenesis of common dermatomycotic species, including Candida yeasts (Candida albicans), dermatophytes (Trichophyton, Epidermophyton or Microsporum species), and other pathogenic yeasts (Malassezia), with a special focus on unique species-specific aspects of the respective infection processes, the interaction between essential aspects of pathogenic infection, the different roles of the host inflammatory response, and the clinical consequences of the infection-related tissue damage and inflammation. We hope that a broader understanding of the various mechanisms of dermatomycoses may contribute to more effective management of affected patients.

Cosmetics for acne: indications and recommendations for an evidence-based approach

AIM

The aim of this review was to evaluate, by a thorough revision of the literature, the true efficacy of currently available topic and systemic cosmetic acne agents.

METHODS

The efficacy of currently available cosmetic acne agents has been retrospectively evaluated via thorough revision of the literature on matched electronic databases (PubMed). All retrieved studies, either randomized clinical trials or clinical trials, controlled or uncontrolled were considered.

RESULTS

Scientific evidence suggests that most cosmetic products for acne may enhance the clinical outcome. Cleansers should be indicated to all acne patients; those containing benzoyl peroxide or azelaic/salicylic acid/triclosan show the best efficacy profile. Sebum-controlling agents containing nicotinamide or zinc acetate may minimize excessive sebum production. Cosmetics with antimicrobial and anti-inflammatory substances such as, respectively, ethyl lactate or phytosphingosine and nicotinamide or resveratrol, may speed acne recovery. Topical corneolytics, including retinaldehyde/glycolic acid or lactic acid, induce a comedolytic effect and may also facilitate skin absorption of topical drugs. Finally, the use of specific moisturizers should be strongly recommended in all acne patients.

CONCLUSION

Cosmetics, if correctly prescribed, may improve the performance of the therapy, whereas wrong procedures and/or inadequate cosmetics may worsen acne. Cosmetological recommendations may allow clinicians to make informed decisions about the role of various cosmetics and to indentify the appropriate indications and precautions. The choice of the most effective product should take into consideration the ongoing pharmacological therapy and acne type/severity as well.

Staphylococcus aureus infection of the feet following fish pedicure

We report a case of Staphylococcus aureus infection of the feet that appeared after a "fish pedicure" (immersion of the feet in a tank with the fish Garra rufa, that nibbles off dead skin). Clinical picture was characterized by maceration, purulent discharge, scales, crusts, itching and burning sensation. Bacteriological examinations were positive for Staphylococcus aureus. Mycological examinations were negative. The patient was successfully treated with ciprofloxacin. Only one case of skin foot infection after fish pedicure was reported so far. Fish pedicure can be a potentially dangerous procedure in immunocompromised or diabetic patients.

Appearance of a reservoir of hookworm-related cutaneous larva migrans in Brittany?

We describe two cases of hookworm-related cutaneous larva migrans acquired in Brittany (North-Western France). The patients were a 23-year-old woman and a 28-year-old man. In both patients the feet were involved. In the second patient, a superinfection due to Staphylococcus aureus was recorded. The appearance in Brittany of a reservoir of nematodes capable of causing hookworm-related cutaneous larva migrans is hypothesized.

Efficacy and tolerability of topical 0.2% Myrtacine® and 4% vitamin PP for prevention and treatment of retinoid dermatitis in patients with mild to moderate acne

AIM

The aim of the present study was to evaluate the efficacy and tolerability of an emulsion of 0.2% Myrtacine® and 4% vitamin PP, compared with a simple emollient cream, in the treatment of retinoid dermatitis in patients with mild-to-moderate acne.

METHODS

This was a prospective, multicenter, open-label, non-randomised, parallel-group study. Patients (age 12-49 years; skin phototype I-IV) with mild-to-moderate acne, who were treated with a topical retinoid for at least one month and had developed skin irritation were assigned to one of the two following treatments: 0.2% Myrtacine® and 4% vitamin PP (N.=116) or a simple emollient cream (N.=48). Both treatments were administered twice daily, 1-1.5 hours after the application of the topical retinoid. Study endpoints were improvement in signs and symptoms of retinoid dermatitis, global efficacy, reduction in acne severity, overall clinical outcome, patient satisfaction and tolerability.

RESULTS

At day 28, compared with the simple emollient cream, 0.2% Myrtacine® and 4% vitamin PP significantly decreased signs (erythema, dryness/scaling, oedema, and roughness) and symptoms (itching, stinging, burning sensation and discomfort) of retinoid dermatitis (P<0.01). In addition, compared with the simple emollient cream, 0.2% Myrtacine® and 4% vitamin PP decreased acne severity in a significantly greater proportion of patients (P=0.023) and was associated with a better clinical outcome (mild, intermediate, clinically relevant or global improvement; P<0.001). 0.2% Myrtacine® and 4% vitamin PP was also associated with greater patient satisfaction and was better tolerated than the simple emollient cream.

CONCLUSION

0.2% Myrtacine® and 4% vitamin PP was effective and well tolerated in the treatment of retinoid dermatitis in patients with mild-to-moderate acne and significantly improved acne severity and overall clinical outcome.

Latency time in cutaneous leishmaniasis

Latency period in cutaneous leishmaniasis was very rarely studied so far. We describe three patients, aged 71, 50 and 32 years, respectively, who contracted cutaneous leishmaniasis in Sicily. In all patients, clinical diagnosis was confirmed by histopathological examination and polymerase chain reaction: the latter was positive for Leishmania infantum in two patients and Leishmania canis in one. All cases were characterized by a very long period of latency, ranging from 11 to 16 months. These cases suggest that latency time of cutaneous leishmaniasis acquired in Sicily may be sometimes very long. The reasons of this latency time are unknown: latency depends neither by the involved species of sandflies and Leishmania nor by the immunological response of the patients: all laboratory tests, including immunological ones, were normal.

Sclerodermus domesticus infestation

AIM

Sclerodermus domesticus is an insect belonging to the order Hymenoptera. Female of S. domesticus feeds on larvae of xylophagous Coleoptera and Lepidoptera living in the galleries they dig in old wooden furniture. Human infestation is rare.

METHODS

In the last few months, we observed nine adult patients (7 males and 2 females) who were affected by S. domesticus infestation. Seven patients were antiquarians or restorers and two were housewives. The rash was characterized by erythematous-papular lesions, accompanied by pruritus and/or pain. In addition, 7 patients reported general malaise and fever. In all cases it was possible to find specimens of S. domesticus in furniture or house dust.

RESULTS

Complete remission was obtained with topical corticosteroids, oral anti-histamines and pest control of furniture.

CONCLUSION

Antiquarians and restorers and, in general, the people in close contact with furniture infested by S. domesticus may be stung by these insects. S. domesticus infestation can therefore be considered as an occupational disease in these subjects.

Minocycline in the treatment of acne: latest findings

Minocycline is a semi-synthetic tetracycline antibiotic effective against a wide range of aerobic and anaerobic Gram-positive and Gram-negative bacteria. It is highly active in the pilosebaceous complex, due to its great lipophilicity, and therefore it has been used in the treatment of moderate to severe papulo-pustular acne for a long time. It has an optimal therapeutic range and the percentage of P. acnes resistant strains are still inferior to 5%. Besides the antimicrobial activity, minocycline has an anti-inflammatory action, due to the reduction in neutrophilic chemotaxis, the inhibitory effect on pro-inflammatory cytokines, and the reduction in sebum free fatty acids and bacterial lipases. In 2006 the Food and Drug Administration (FDA) approved a new extended-release formulation of minocycline. This formulation allowed the reduction of some dose-related adverse events, such as those affecting the vestibular system. Besides the dose-related events (nausea, vomiting, and dizziness), minocycline is also known to induce hyperpigmentation, even if less frequently than doxycycline, and is rarely responsible for autoimmune disorders, hypersensitivity reactions, and serum sickness-like reactions. The latest guidelines in the treatment of acne recommend a dose of 50-100 mg, once or twice a daily for the non-modified release minocycline, and 1 mg/kg daily for the new extended-release formulation. This agent is most appropriately used in combination with a topical regimen containing benzoyl peroxide and/or retinoid.

Cutaneous myiasis caused by Dermatobia hominis acquired in Jamaica

The authors describe a case of cutaneous myiasis caused by Dermatobia hominis in a 23-year-old Italian woman who contracted the infestation during a tour in Jamaica. The infestation was located on the back and was characterized clinically by a single inflammatory nodule. To our knowledge, this is the first case of cutaneous myiasis due to Dermatobia hominis acquired in Jamaica.

Erysipeloid: a review

Erysipeloid is an occupational infection of the skin caused by traumatic penetration of Erysipelothrix rhusiopathiae. The disease is characterized clinically by an erythematous oedema, with well-defined and raised borders, usually localized to the back of one hand and/or fingers. Vesicular, bullous and erosive lesions may also be present. The lesion may be asymptomatic or accompanied by mild pruritus, pain and fever. In addition to cutaneous infection, E. rhusiopathiae can cause endocarditis, which may be acute or subacute. Endocarditis is rare and has a male predilection. It usually occurs in previously damaged valves, predominantly the aortic valve. Endocarditis does not occur in patients with valvular prostheses and is not associated with intravenous drug misuse. Diagnosis of localized erysipeloid is based on the patient's history (occupation, previous traumatic contact with infected animals or their meat) and clinical picture (typical skin lesions, lack of severe systemic features, slight laboratory abnormalities and rapid remission after treatment with penicillin or cephalosporin).

Erysipeloid

We report a case of erysipeloid in a 73-year-old woman. The disease was characterized clinically by erythematous and erosive lesions on three fingers of the left hand. Diagnosis was made based on the patient's occupation (housewife), history of previous traumatic contact with a scorpion fish, typical inflammatory lesions located on one hand, lack of severe systemic features, mild laboratory abnormalities and rapid remission after specific treatment.

Multiple aphthoid syphilitic chancres of the oral cavity

Summary

We describe the case of a 31-year-old man who was affected by three asymptomatic, aphthoid, syphilitic chancres of the oral cavity. These lesions were accompanied by right latero-cervical and chin lymphadenopathy. The infection was previously diagnosed as aphthous stomatitis. The search for Treponema pallidum by means of darkfield microscope examination was positive. The patient was successfully treated with oral erythromycin ethylsuccinate. To our knowledge, this is the first case of multiple aphthoid syphilitic chancres of the oral cavity reported in the literature. We suggest that all patients with a recent history of painless ulcers in the oral cavity, accompanied by regional lymphadenopathy in which the clinical diagnosis has not been confirmed, should undergo a darkfield microscope examination.

Cutaneous larva migrans with folliculitis: a new clinical presentation of this infestation

Two patients (a 35-year-old woman and a 33-year-old man, just returned from trips to Jamaica and Barbados, respectively) presented with cutaneous larva migrans with folliculitis, a rare and atypical clinical presentation of this infestation. Histopathological examination revealed a follicular and perifollicular infiltrate prevalently consisting of lymphocytes and neutrophils, with numerous eosinophils. Both patients were successfully treated with oral albendazole.

A randomised, double-blind, vehicle-controlled study to evaluate the efficacy and safety of MAS063D (Atopiclair) in the treatment of mild to moderate atopic dermatitis

MAS063D (Atopiclair is a hydrolipidic cream that has been developed for the management of atopic dermatitis (AD). The putative active ingredients of MAS063D are hyaluronic acid, telmesteine, Vitis vinifera, glycyrrhetinic acid. A five-week study in 30 adult patients with mild to moderate AD showed that MAS063D offered significant benefits over a vehicle-only control. MAS063D improved the total body area affected (17.2% --> 13.2%, p < 0.001), itch score (2.7 --> 1.3 on a 10-point scale, p = 0.001) and EASI score (28.3 --> 24.3, p = 0.024) after 22 days treatment compared to baseline. The patients' opinion of MAS063D (patient's view of itch control, and view of study substance) was rated by participating patients as significantly better than control (p = 0.008, p = 0.042 respectively). Based on these preliminary results in a small scale study, it is suggested that MAS063D is a possible new treatment option for improving signs and symptoms in adults with mild to moderate AD.

Case report. Erythrasmoid pityriasis versicolor

A 50-year-old Caucasian man with pityriasis versicolor that was localized almost exclusively in the inguinal folds and was characterized by lesions clinically superimposable on those of erythrasma is described. Due to these clinical characteristics, it is proposed that this variety of pityriasis versicolor is defined as 'erythrasmoid'.