Randomized controlled trial and cost-effectiveness analysis: Comparing chlorhexidine scrub, ZnO-nanoparticle socks, and their combination in pitted keratolysis treatment.

A cost-effective treatment for pitted keratolysis (PK) is the use of 4% chlorhexidine scrub. Zinc oxide nanoparticle (ZnO-NP)-coated socks have also shown efficacy in PK prevention. In this study, we aimed to assess the cost-effectiveness and safety of combined 4% chlorhexidine scrub and ZnO-NP-coated sock treatment compared to monotherapy. This randomized, controlled trial included 60 male security guards and hospital porters aged ≥18 with PK. Participants were randomly assigned to one of three treatment groups: 4% chlorhexidine scrub, ZnO-NP-coated socks, or combination therapy. Treatment outcomes were evaluated after 4 weeks. Incremental cost-effectiveness ratios (ICERs) were calculated using cost-utility analysis. The greatest reduction in visual analog scale scores for foot odor was observed in the combination therapy group, but it was nonsignificant (P = 0.186). Clinical improvement was observed across all groups. The cost-utility analysis revealed that chlorhexidine scrub and regular socks were the least expensive options. The placebo and ZnO-NP-coated sock group had an ICER of US $31 082/quality-adjusted life years (QALYs) gain, while the combination therapy gained US $45 105/QALYs compared to the chlorhexidine scrub and regular sock group. Based on our findings, for the treatment of PK, 4% chlorhexidine scrub remains the most cost-effective choice.

Cutaneous Fungal Infections Caused by Dermatophytes and Non-Dermatophytes: An Updated Comprehensive Review of Epidemiology, Clinical Presentations, and Diagnostic Testing.

Cutaneous fungal infection of the skin and nails poses a significant global public health challenge. Dermatophyte infection, mainly caused by Trichophyton spp., is the primary pathogenic agent responsible for skin, hair, and nail infections worldwide. The epidemiology of these infections varies depending on the geographic location and specific population. However, epidemiological pattern changes have occurred over the past decade. The widespread availability of antimicrobials has led to an increased risk of promoting resistant strains through inappropriate treatment. The escalating prevalence of resistant Trichophyton spp. infections in the past decade has raised serious healthcare concerns on a global scale. Non-dermatophyte infections, on the other hand, present even greater challenges in terms of treatment due to the high failure rate of antifungal therapy. These organisms primarily target the nails, feet, and hands. The diagnosis of cutaneous fungal infections relies on clinical presentation, laboratory investigations, and other ancillary tools available in an outpatient care setting. This review aims to present an updated and comprehensive analysis of the epidemiology, clinical manifestations, and diagnostic testing methods for cutaneous fungal infections caused by dermatophytes and non-dermatophytes. An accurate diagnosis is crucial for effective management and minimizing the risk of antifungal resistance.

Efficacy and Safety of Clinacanthus nutans Lindau Cream vs. Podophyllin for the Treatment of Adults with Condyloma Acuminata.

Human papillomavirus (HPV) infection causes condyloma acuminata (CA). Podophyllin is the standard treatment. Clinacanthus nutans Lindau (C. nutans), a medicinal plant, has potent anti-inflammatory and antiviral effects. C. nutans cream is widely used in Thailand to treat the herpes simplex virus. We proposed that C. nutans might also induce CA clearance. There are no studies of C. nutans treatment of CA. This randomized controlled trial at Siriraj Hospital, Thailand, was conducted between January 2018 and December 2019. CA samples were obtained from 10 men with at least two CAs 1 centimeter apart. Each wart was randomized to a 4-week treatment with either C. nutans or podophyllin. The participants were 24 to 72 years old. Most HPV types were low-risk HPVs (HPV 11, HPV 6). Median CA clearance with podophyllin was a 97% CA clearance with podophyllin and 82% with C. nutans. C. nutans may be an alternative treatment for CA.

The Correlations between Clinical Features, Dermoscopic and Histopathological Findings, and Treatment Outcomes of Patients with Pitted Keratolysis.

BACKGROUND: Pitted keratolysis (PK) is a superficial bacterial infection diagnosed mainly by clinical manifestations. Current data on its dermoscopic and histopathological findings, and the correlation of those findings, are limited. OBJECTIVES: To evaluate the clinical manifestations, dermoscopic, and histopathological findings of PK and to determine the correlations. METHODS: Forty naval cadets with PK and five cadets with normal feet were enrolled this cohort study and provided informed consent. Dermoscopy was independently applied and evaluated by 2 dermatologists. Shave biopsies were performed on 37 patients with PK. RESULTS: Pits were the most common dermoscopic finding (88.1%). The dermoscope had more sensitivity for the detection of PK than the naked eye examinations. Apart from the pits and the presence of bacteria, the most common histopathological finding for PK was color alteration of keratin. The presence of bacteria correlated with interrupted dermatoglyphic lines and the color alteration of keratin. Moreover, the presence of bacteria at the base of pits was related to worse treatment outcomes. CONCLUSIONS: Dermoscopy is a useful tool for PK diagnosis. Color alteration of keratin is another histopathological finding for PK. The presence of bacteria is associated with worse treatment outcomes.

Adult female acne: Clinical characteristics and factors significantly associated with polycystic ovary syndrome.

BACKGROUND: Adult female acne (AFA) may be different from adolescent acne, and may be a sign of polycystic ovary syndrome (PCOS). The objective of the study was to investigate the clinical characteristics of AFA, and the factors significantly associated with PCOS in AFA. METHODS: AFA patients aged 25 years or older were enrolled. History taking and dermatologic examinations were performed by dermatologists. PCOS was diagnosed by gynaecologists. Perimenopausal acne (aged 45 years or older) and the Dermatology Life Quality Index (DLQI) were also evaluated. RESULTS: Among 208 patients, mean age was 31.8 ± 7.1 years and 47.1%, 26.9%, and 26% had persistent, late-onset, and recurrent acne, respectively. The common aggravating factors included pre-menstruation (72.6%) and stress (53.8%). Recurrent acne was significantly aggravated by cosmetic products. Higher body mass index (BMI) was positively correlated with acne severity. Acne lesions were predominately located on both cheeks (87.0%) and at the perioral area (81.7%). PCOS was identified in 48.1%. Younger age (≥25 to <33 years), premenstrual flare, and irregular menstruation, but not hirsutism or androgenetic alopecia, were associated with PCOS in univariate and multivariate analysis. Perimenopausal acne was identified in 6.7%. The total mean DLQI score was 8.0 ± 5.4 (range from 0 to 23). CONCLUSIONS: Persistent acne with moderate severity was common in AFA patients and higher BMI was associated with acne severity. PCOS should be screened in AFA patients with younger age, premenstrual flare, and irregular menstruation.

Randomized controlled trial comparing long-pulsed 1064-Nm neodymium: Yttrium-aluminum-garnet laser alone, topical amorolfine nail lacquer alone, and a combination for nondermatophyte onychomycosis treatment.

BACKGROUND: Studies of the laser treatment of nondermatophyte mold (NDM) onychomycosis are limited. Long-pulsed neodymium:yttrium-aluminum-garnet (Nd:YAG) 1064-nm laser has been introduced as an adjuvant dermatophyte onychomycosis treatment. AIMS: To investigate the efficacy and safety of long-pulsed Nd:YAG 1064-nm laser for NDM onychomycosis treatment, compared with topical amorolfine nail lacquer alone and a combination treatment. PATIENTS/METHODS: This randomized controlled trial was conducted at the Nail Clinic, Siriraj Hospital. Patients diagnosed with NDM were included and randomly assigned to three treatment groups: laser at 1 month interval (1064-nm Nd:YAG at a fluence of 35 J/cm2 , pulse width 30 ms, and pulse rate 1.0 Hz); topical amorolfine nail lacquer alone; and a combination treatment. RESULTS: Sixty patients completed the study. The patients treated with the laser, amorolfine, and the combination achieved mycological cure rates of 35%, 60%, and 65%, respectively (P = .05), while 10%, 30%, and 30% of the patients in the respective groups were clinically cured. The mean durations to the mycological cures in the patients treated with laser, amorolfine, and the combination were 5.9, 4.8, and 5.2 months, respectively. By comparison, the corresponding mean durations to the clinical cures were 6.9, 6.5, and 5.9 months. Both the times to the mycological cures and the clinical cures did not differ significantly between the groups (P = .290 and P = .309, respectively). There were no serious complications with the laser treatment. CONCLUSIONS: Laser alone achieved only a 30% mycological cure rate for NDM onychomycosis. The combination treatment yielded similar outcomes to the topical treatment alone.

Predictors of serological cure after treatment in patients with early syphilis: A retrospective observational study in Thailand.

BACKGROUND: Some patients with early syphilis who receive appropriate treatment do not reach a serological cure and have a persistent titer which does not meet the criteria for treatment failure (serofast state). AIMS: This retrospective study aimed to determine the prevalence of serological cure and the serofast state as well as the factors associated with serological cure after treatment of patients with early syphilis. METHODS: A serological cure was defined as occurring when there was a ≥4-fold decrease in nontreponemal titer, whereas patients with a ≥4-fold increase were considered as having either a treatment failure or reinfection. Nontreponemal titers that neither increased nor decreased ≥4-fold after treatment were considered to be in a serofast state. Seroreversion was defined as occurring when there was a negative test within 12 months of treatment. RESULTS: There were 179 patients with a mean age of 31.9 years; 174 (97.2%) were men, and 125 (70%) were HIV patients. Of the total, 174 (98%; 95% confidence interval 94.82-99.42%) patients achieved a serological cure, whereas five were in a serofast state 12 months after treatment. Those five serofast patients were all HIV-positive men, of which 4 (80%) had secondary-stage syphilis, a CD4 count ≤200 cells/µl and a titer <1:8. In a bivariate analysis, a serological cure was associated with a baseline Venereal Disease Research Laboratory >1:16 titers (P = 0.018), and a CD4 cell count >200 cells/µl in 6 months preceding treatment (P = 0.016). The median time to a serological cure was 96 days. Only 22 (12.3%) of the patients achieved seroreversion at 12 months after treatment. LIMITATIONS: A retrospective medical record review is likely to have a selection bias, and in our study, 196 (52%) patients were excluded due to missing information. CONCLUSIONS: Most patients with early syphilis who achieved a serological cure at 12 months after treatment had high baseline Venereal Disease Research Laboratory titers and CD4 cell counts. However, only 22 (12.3%) had a negative Venereal Disease Research Laboratory titer after 1 year of treatment.

Cost-effectiveness analysis and safety of erythromycin 4% gel and 4% chlorhexidine scrub for pitted keratolysis treatment.

Background: Studies of Pitted keratolysis (PK) treatment are limited. Objectives: To study cost-effectiveness and to compare the safety of 4% chlorhexidine scrub with 4% erythromycin gel, for PK infections. Materials and methods: This cohort study was conducted on naval rating cadets with a clinical diagnosis of PK at Chumpol Naval Rating School, Thailand in 2016. Participants were randomly treated with either 4% erythromycin gel or 4% chlorhexidine scrub for 4 weeks. The clinical examinations were evaluated at the baseline and at 1 and 2 months after treatment. A decision-tree model was used to evaluate the costs, resource utilization and outcomes as quality-adjusted life-years (QALYs). Results: Of 344 naval rating cadets, 125 (36.3%) were diagnosed with PK. Sixty-four were treated with erythromycin. Approximately 80% of participants had complete resolution Foot odor were significantly improved at 2 months (p < .001) for both groups. No adverse effects were reported. Total cost for 4 weeks' treatment with the erythromycin gel and chlorhexidine scrub was US$77.34, US$51.9, respectively. Chlorhexidine treatment and erythromycin gel had 0.1526 and 0.1425 QALYs, respectively. Conclusions: treatment of PK with either 4% chlorhexidine scrub or 4% erythromycin gel had similar outcomes. However, using chlorhexidine scrub was more cost-effective.

Subcutaneous phaeohyphomycosis from Medicopsis romeroi in a diabetic patient.

Dematiaceous fungi can cause subcutaneous phaeohyphomycosis, an uncommon fungal infection of the dermis and subcutaneous tissues. Medicopsis romeroi is an emerging organism that can infect patients with subcutaneous phaeohyphomycosis, especially immunocompromised patients. The present case involved subcutaneous phaeohyphomycosis caused by Medicopsis romeroi in an 80-year-old Thai male with poorly controlled diabetes, for whom the lesion underwent spontaneous remission after his glycemic control was improved. Furthermore, cases of subcutaneous phaeohyphomycosis for the last 10 years were reviewed.

Interobserver reliability of histopathological features for distinguishing between cutaneous polyarteritis nodosa and superficial thrombophlebitis.

AIMS: Interobserver reliability of histopathological features in differentiation between cutaneous polyarteritis nodosa (cPAN) and superficial thrombophlebitis (ST) by assessment of inter-rater agreement of five histological features was investigated. METHODS AND RESULTS: All sections of cPAN and ST were evaluated independently by three experienced pathologists and one resident of pathology. The histopathological features studied included elastic fibre distribution in the vascular wall, a smooth muscle arrangement pattern, an internal elastic lamina pattern, fibrinoid necrosis and luminal thrombosis. Agreement analysis was performed using the kappa coefficient. Sensitivity, specificity, positive predictive value (PPV), positive likelihood ratio (PLR) and 95% confidence interval (95% CI) of the useful histopathological features were analysed. Of all 62 biopsies, 28 were cPAN and 34 were ST. Reproducibility between four observers was in substantial agreement (κ = 0.73). Elastic fibre distribution in the vascular wall (κ = 0.68), fibrinoid necrosis (κ = 0.63), an internal elastic lamina pattern (κ = 0.51) and a smooth muscle arrangement pattern (κ = 0.46) showed high specificity and PPV for differentiating between cPAN and ST. The smooth muscle arrangement pattern, internal elastic lamina pattern and elastic fibre distribution in the vascular wall may be obscured when extensive inflammation and necrosis occurs. CONCLUSIONS: These aforementioned histopathological features are useful in differentiation between cPAN and ST. The Verhoeff-van Gieson (VVG) elastic stain is an important histochemical study for differentiating between cPAN and ST, particularly in cases with extensive inflammation and necrosis.

Treatment outcomes and loss to follow-up rate of male patients with gonococcal and nongonococcal urethritis who attended the sexually transmitted disease clinic: An 8-year retrospective study.

BACKGROUND: Poor follow-up compliance of patients with infectious urethritis is a recognized and serious public health problem in Thailand. AIM: The aim of this study was to determine treatment outcomes and loss to follow-up rate of male patients with gonococcal urethritis (GU) and non-GU (NGU) at a sexually transmitted disease (STD) clinic at Thailand's tertiary hospital. METHODS: This retrospective chart review of male patients who sought treatment at STDs Clinic, Siriraj Hospital, and who were diagnosed with GU and/or NGU was conducted during January 2007 to December 2014 study period. RESULTS: Two hundred and twenty-seven male urethritis patients were included in this study with a mean age was 29.5 years. GU and NGU were found in 120 (52.9%) and 107 (47.1%) of patients, respectively. Overall prevalence of GU and NGU during the 8-year study period at STD Clinic, Siriraj Hospital, was 8.6% and 7.8%, respectively. Ninety-six patients (42.3%) were lost to follow-up. Recurrent urethritis was found in 23.8% of patients, and HIV infection was identified in 11.6%. Mean age of patients lost to follow-up was 29 years. Compared with patients who attended every scheduled follow-up visit, men who have sex with men had a significantly lower rate of loss to follow-up (P = 0.012). CONCLUSION: Almost half of patients with GU or NGU were lost to follow-up, and one-quarter had recurrent urethritis. Fast and easy access to services that provide accurate diagnostic testing and effective treatment should be a public health priority to prevent complications and reduce rates of disease transmission.

Clinical practice guideline for diagnosis and management of urticaria.

Urticaria is a common skin condition that can compromise quality of life and may affect individual performance at work or school. Remission is common in majority of patients with acute spontaneous urticaria (ASU); however, in chronic cases, less than 50% had remission. Angioedema either alone or with urticaria is associated with a much lower remission rate. Proper investigation and treatment is thus required. This guideline, a joint development of the Dermatological Society of Thailand, the Allergy, Asthma, and Immunology Association of Thailand and the Pediatric Dermatological Society of Thailand, is graded and recommended based on published evidence and expert opinion. With simple algorithms, it is aimed to help guiding both adult and pediatric physicians to better managing patients who have urticaria with/without angioedema. Like other recent guideline, urticaria is classified into spontaneous versus inducible types. Patients present with angioedema or angioedema alone, drug association should be excluded, acetyl esterase inhibitors (ACEIs) and non-steroidal anti-inflammatory drugs (NSAIDs) in particular. Routine laboratory investigation is not cost-effective in chronic spontaneous urticaria (CSU), unless patients have clinical suggesting autoimmune diseases. Non-sedating H1-antihistamine is the first-line treatment for 2-4 weeks; if urticaria was not controlled, increasing the dose up to 4 times is recommended. Sedating first-generation antihistamines have not been proven more advantage than non-sedating antihistamines. The only strong evidence-based alternative regimen for CSU is an anti-IgE: omalizumab; due to very high cost it however might not be accessible in low-middle income countries. Non-pharmacotherapeutic means to minimize hyper-responsive skin are also important and recommended, such as prevention skin from drying, avoidance of hot shower, scrubbing, and excessive sun exposure.

Human cervix: an alternative substrate for detecting circulating pemphigus antibodies.

Monkey esophagus (ME) is a well-accepted substrate for diagnosing pemphigus vulgaris (PV) by indirect immunofluorescence (IIF). However, its availability is sometimes limited due to ethical concerns. This study aimed to investigate the usefulness of human cervix (HC) as a substrate in the diagnosis of PV by IIF. Initially, serum from 1 PV patient was incubated with tissues from 48 HCs. Median IIF titers on HCs that had different demographic and clinical characteristics were compared. Sera from 5 PV patients were then incubated with ME and 21 HCs. For each serum, the titer of IIF on HC that was not different from ME by more than two-fold dilutions was acceptable. Last, sera from 42 PV, 14 pemphigus foliaceous, and 62 non-pemphigus patients were used to evaluate sensitivity and specificity. The results demonstrate that differences in demographic data among HCs did not affect IIF titers. Titers obtained from ME and HC were comparable (81-100 % acceptable values). Sensitivity of HC for diagnosis of PV was better than for diagnosis of pemphigus foliaceus (90.5 and 71.4 %, respectively). Specificity for PV and PF was 96.2 %. We proposed that HC substrate can be used as an alternative substrate for diagnosis of PV by IIF.