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.

New insights on ocular surface disease in patients with atopic dermatitis treated with dupilumab.

Our study sought to describe ocular surface alterations at baseline and after 4 months of dupilumab treatment in patients with severe AD. Our findings highlight that all 25 patients showed ocular surface alterations prior to dupilumab treatment. Dupilumab may cause the worsening of clinical or subclinical pre-existing ocular alterations belonging to the spectrum of AKC.

Autologous bilayered self-assembled skin substitutes (SASSs) as permanent grafts: a case series of 14 severely burned patients indicating clinical effectiveness.

Split-thickness skin autografts (AGs) are the standard surgical treatment for severe burn injuries. However, the treatment of patients with substantial skin loss is limited by the availability of donor sites for skin harvesting. As an alternative to skin autografts, our research group developed autologous self-assembled skin substitutes (SASSs), allowing the replacement of both dermis and epidermis in a single surgical procedure. The aim of the study was to assess the clinical outcome of the SASSs as a permanent coverage for full-thickness burn wounds. Patients were recruited through the Health Canada's Special Access Program. SASSs were grafted on debrided full-thickness wounds according to similar protocols used for AGs. The graft-take and the persistence of the SASS epithelium over time were evaluated. 14 patients received surgical care with SASSs. The mean percentage of the SASS graft-take was 98 % (standard deviation = 5) at 5 to 7 d after surgery. SASS integrity persisted over time (average follow-up time: 3.2 years), without noticeable deficiency in epidermal regeneration. Assessment of scar quality (skin elasticity, erythema, thickness) was performed on a subset of patients. Non-homogeneous pigmentation was noticed in several patients. These results indicated that the SASS allowed the successful coverage of full-thickness burns given its high graft-take, aesthetic outcome equivalent to autografting and the promotion of long-term tissue regeneration. When skin donor sites are in short supply, SASSs could be a valuable alternative to treat patients with full-thickness burns covering more than 50 % of their total body surface area.

Superior eyelid incision: an alternative approach for frontozygomatic dermoid cyst excision.

Sixty-five children presenting with frontozygomatic (lateral brow) dermoid cysts were operated using an upper eyelid crease incision. There were 38 girls and 27 boys age 3 months to 13 years (mean age, 15 months). The lesions were left sided in 32 patients and right sided in 33 patients. Preoperative radiograph or computed tomographic scan performed for 25 children failed to demonstrate a bony defect in the area of the cyst. At surgery, 14% of the cysts were adherent to the periosteum and 5% were subperiosteal. One cyst extended through the bone into the orbit. All cysts were removed completely, and this was accomplished without rupture in 54 patients. The average operating time was 21 minutes. All children were seen within 1 month of surgery. The postoperative course was uneventful except for early swelling and erythema in 2 children. Thirty-six patients (55%) could be reached for long-term follow-up (range, 1-7.1 years) postoperatively. The authors found no lid or ocular dysfunction and excellent scar camouflage in all patients.

Otoplasty: anterior scoring technique and results in 500 cases.

Corrective otoplasty is a commonly performed procedure to change the shape of the auricular cartilage. Many techniques use permanent sutures to maintain the cartilage folding, whereas other techniques rely on cartilage incisions (partial thickness or full thickness). At this institution, a cartilage cutting and anterior scoring technique has been used for more than 30 years with pleasing results. The surgical techniques published in the past have been reviewed and compared with the procedure used at this institution to point out the advantages, disadvantages, and differences of these various techniques. Also reviewed were 500 consecutive cases operated on under local or general anesthesia between January of 1993 and December of 1995 to determine the incidence of early and late complications. The patients were contacted by mail to return for a follow-up examination or answer a questionnaire, at least 2 years after the procedure. Early complications were bleeding in 13 cases (2.6 percent) and hematoma in 2 cases (0.4 percent). There were no infections or ear necrosis. A small cutaneous wound was present on the anterior skin in three patients (0.6 percent), and there was one wound dehiscence (0.2 percent). Late complications were keloids in two cases and inclusion cysts in three cases. Residual deformity was noted in 22 cases and asymmetry in 28 cases. Secondary surgery was performed in six cases. The questionnaire was answered by 387 patients (77.4 percent response rate): pain when the ear is touched was present in 22 cases (5.7 percent), hypesthesia in 15 cases (3.9 percent), occasional cutaneous irritation in 38 cases (9.8 percent), asymmetry in 71 cases (18.4 percent), and abnormal ear shape in 17 cases (4.4 percent). Twenty-nine patients (7.5 percent) also noted that the ear was more sensitive to cold or touch. The satisfaction rate was 94.8 percent: very satisfied, 74 percent; satisfied, 20.8 percent; dissatisfied, 4.2 percent; and very dissatisfied, 1 percent. These results were compared with other published series of complications and late results after otoplasty; the complication rates are similar or lower in this study. Therefore, it can be concluded that the cartilage cutting and anterior scoring technique otoplasty is a safe procedure with a high patient-parent-surgeon satisfaction rate.

Cervical chrondrocutaneous branchial remnants.

Similar in appearance to preauricular tags but located in the lateral neck, cervical chondrocutaneous branchial remnants are a rather less common and less well known congenital lesion. A retrospective review of admissions at Sainte-Justine Hospital between 1980 and 1993 produced 20 cases of cervical tags, of which 17 were true cervical chrondrocutaneous branchial remnants and 3 were skin tags associated with a thyroglossal duct. Of the 17 true cervical chrondrocutaneous branchial remnants, 15 were operated on in our institution. The clinical characteristics, results of investigations, surgical data, pathologic findings, and associated anomalies were documented. Several interesting facts emerged, including a male predominance (11 of 17), a scarcity of bilateral lesions (1 of 17), the presence of an elastic cartilage core in all operated specimens (15 of 15), and a high incidence of associated anomalies (13 of 17). We suggest that the second branchial arch is the most likely origin for the lesion. We propose a clear, widely acceptable name for this anomaly in order to prevent further diagnostic confusion. Most important, although simple surgical excision is all that is required for treatment, a complete physical examination of the patient and possibly an ultrasound examination of the genitourinary tract are recommended because a cervical chrondrocutaneous branchial remnant has proven in many cases to be a visible "marker" for more serious associated anomalies.

Nasal dermoid sinus cysts: an unusual presentation, computed tomographic scan findings, and surgical results.

Midline nasal dermoid cysts are congenital lesions resulting from aberrant embryological development. Accurate diagnosis and effective treatment are essential to avoid craniofacial skeletal deformations, cyst rupture, and infection that could cause cutaneous, ocular, or intracranial complications. We report an unusual case of congenital midline nasal dermoid cysts in which an 18-month-old child presented to a hospital emergency department with periorbital cellulitis. It resulted from multiple midline nasal dermoid cysts involving the nasal, forehead, and both orbital regions but without intracranial extension. The patient was successfully managed with a craniofacial approach.

Intracranial nasal dermoid sinus cysts: computed tomographic scan findings and surgical results.

From July 1987 to January 1991, 14 patients, ages 1 to 19 years (mean 6 years), were seen with nasal dermoid sinus cysts, a congenital lesion with the potential for intracranial extension. Each patient was assessed clinically for cyst location, symptoms, associated craniofacial deformity, and other congenital anomalies. In 5 (36 percent) of the 14 patients, ages 4 to 48 months (mean 25 months), computed tomographic scans indicated indirect signs of intracranial extension, which were confirmed intraoperatively and histologically in all 5 patients. After neurosurgical consultation, a combined single-stage intracranial-extracranial approach was used to excise the lesion. No perioperative complications occurred. Clinical assessment (follow-up 20 to 40 months, mean 31 months), confirmed by postoperative CT scan 1 year after surgery, indicated no evidence of recurrence, residual skeletal contour defects, or deformity; forehead and nasal growth were qualitatively normal, and scar appearance was satisfactory. Our experience indicates that intracranial extension of nasal dermoid sinus cysts seen at a tertiary care referral center are not rare, that computed tomography scan permits accurate diagnosis, and that the single-stage intracranial-extracranial approach to resection is effective and results in minimal morbidity.

Neonatal Volkmann's ischemic contracture of the forearm: a report of five cases.

We report five cases of children born with forearm wounds associated with motor and sensory losses to the hand and forearm. Their evolution toward muscle retraction is very similar to the classic description of Volkmann's ischemic contracture. These cases should not be confused with upper extremity gangrene of the newborn or aplasia cutis congenita. Two cases of neonatal Volkmann's ischemia have already been reported in the literature and identified as such. Another very similar case has been reported as upper extremity gangrene of the newborn, and three more cases of a forearm wound with neuromuscular involvement have been reported as aplasia cutis congenita. We believe that neonatal Volkmann's ischemic contracture of the forearm should be recognized as a separate entity. Its early diagnosis may improve treatment, especially for children with recent injury, in whom intracompartmental pressures may still be elevated. Early hand therapy and splinting are mandatory to minimize late sequelae.