A Randomized Clinical Trial on Therapeutic Effects of Myrtus communis L. Cream on Chronic Skin Lesions and Quality of Life of Sulfur Mustard-exposed Veterans

Abstract: Sulfur mustard is one of the chemical warfare agent. It rapidly reacts with the cutaneous tissues and other tissues, leading to various devastating long-term effects on human health. Mustard-exposed veterans suffer from its chronic skin problems, including itching, burning sensation, and eczema. We aimed to evaluate the protective effects of Myrtus communis L. (myrtle) on chronic skin lesions and quality of life of sulfur mustard-exposed veterans. In this randomized, double-blind clinical trial, 60 sulfur mustard-exposed patients were evaluated. Thirty patients received myrtle essence 5% cream (case group) and 30 patients received Eucerin cream (placebo group) twice in a day for one month. Then, We assessed the chronic skin problems and itching-related parameters (such as the itching time, severity, distribution, frequency, and calculated itching score), duration of sleep, number of waking up at night, and quality of life in the both groups. Our analysis of data revealed that application of myrtle cream effectively decreased skin problems including; itching and burning sensation. Additionally, myrtle markedly decreased skin lesion symptoms such as excoriation in the case group as compared with before treatment. Noticeably, myrtle cream significantly improved quality of life of the patients in the case group. The present study provides more in-depth information regarding the protective role of myrtle on the sulfur mustard-induces skin complication. Also, myrtle effectively improved quality of life of the sulfur mustard-exposed veterans.

Possible treatment with medicinal herbs and their ingredients of lung disorders induced by sulfur mustard exposures: a review.

Chemical warfare (CW) agents are toxic synthetic chemicals that affect human's health, and sulfur mustard (SM) is a well-known chemical weapon that caused deaths of victims. The lung is the main target of SM exposure, and there are no definitive therapeutic modalities for lung injury induced by this agent. The possible therapeutic effects of medicinal plants and their active ingredients on lung injury induced by SM were reviewed in this article until the end of June 2021. Medicinal plants including Crocus sativus, Curcuma longa, Thymus vulgaris, Nigella sativa, and Zataria multiflora and also natural compounds showed therapeutic potential in improving of various features of lung injury induced by SM and other related chemical agents. Several studies showed therapeutic effects of some medicinal plants and natural products on lung inflammation, oxidative stress, and immune responses in experimental studies in SM-induced lung injury. In addition, clinical studies also showed the effect of medicinal plants and natural compounds on respiratory symptoms, pulmonary function tests (PFTs), and inflammatory markers. The therapeutic effects of medicinal plants and natural products on lung disorder induced by SM and related chemical agents were shown through amelioration of various features of lung injury.

Nuclear magnetic resonance-based plasma metabolomics revealed the protective effect of tea polyphenols on sulfur mustard-induced injury in rats.

Tea polyphenols (TP) are the major antioxidant components from tea, which could be beneficial to oxidative stress injury, such as sulfur mustard (SM) exposure. However, the holistic efficacy of TP on SM poisoning remains unexplored and needs further investigation. In this study, Nuclear magnetic resonance(NMR)-based metabolomics along with multivariate statistical analysis was used to explore the metabolic alteration after SM injury and the protective mechanism of TP. Thirteen potential plasma biomarkers of SM injury were identified, which primarily related to synthesis of ketone bodies, arginine and proline metabolism, butanoate metabolism and alanine aspartate and glutamate metabolism. After TP pre-treatment, the biomarkers were mostly restored to normal levels, which suggested that TP provided effective protection against SM injury and might play its role by rebalancing disordered metabolism pathways. This work enhanced our comprehension of the metabolic profiling of SM injury and revealed the protective mechanism of TP.

NAD+ in sulfur mustard toxicity.

Sulfur mustard (SM) is a toxicant and chemical warfare agent with strong vesicant properties. The mechanisms behind SM-induced toxicity are not fully understood and no antidote or effective therapy against SM exists. Both, the risk of SM release in asymmetric conflicts or terrorist attacks and the usage of SM-derived nitrogen mustards as cancer chemotherapeutics, render the mechanisms of mustard-induced toxicity a highly relevant research subject. Herein, we review a central role of the abundant cellular molecule nicotinamide adenine dinucleotide (NAD+) in molecular mechanisms underlying SM toxicity. We also discuss the potential beneficial effects of NAD+ precursors in counteracting SM-induced damage.

Role of oxidative stress and antioxidant therapy in acute and chronic phases of sulfur mustard injuries: a review.

Sulfur mustard (SM) is a chemical compound that preferentially targets ocular, cutaneous and pulmonary tissues. Although pathologic effect of SM has been extensively considered, molecular and cellular mechanism of its toxicity, especially at the chronic phase of injury is not well-understood. Excessive production of reactive oxygen species (ROS) and oxidative stress (OS) appears to be involved in SM-induced injuries. SM may trigger several molecular and cellular pathways linked to OS and inflammation that can subsequently result in cell death and apoptosis. At the acute phase of injury, SM can enhance ROS production and OS by reducing the activity of antioxidants, depletion of intercellular glutathione (GSH), decreasing the productivity of GSH-dependent antioxidants, mitochondrial deficiency, accumulation of leukocytes and pro-inflammatory cytokines. Overexpression of ROS producing enzymes and down-regulation of antioxidant enzymes are probably the major events by which SM leads to OS at the chronic phase of injury. Therefore, antioxidant therapy with potent antioxidants such as N-acetylcysteine and curcumin may be helpful to mitigate SM-induced OS damages. This review aims to discuss the proposed cellular and molecular mechanisms of acute and delayed SM toxicity, the importance of OS and mechanisms by which SM increases OS either at the acute or chronic phases of injuries along with research on antioxidant therapy as a suitable antidote.

The effect of Zataria multiflora on pulmonary function tests, hematological and oxidant/antioxidant parameters in sulfur mustard exposed veterans, a randomized doubled-blind clinical trial.

BACKGROUND: Sulfur mustard is an alkylating agent which cause to short and long term incapacitations on various organs including lung. There is no definite treatment for lung disorders induced by SM exposure. In the present study, the preventive effect of Zataria multiflora (Z. multiflora) on hematological parameters, oxidant/antioxidant markers and pulmonary function tests (PFT) in veterans, 27-30 years after exposed to SM were studied. MATERIALS AND METHODS: Forty seven veterans allocated to three groups included: placebo group (P) and two groups treated with 5 and 10 mg/kg/day of Z. multiflora (Zat 5 and Zat 10). Drugs were prescribed in a double-blind manner for two months. Total and different WBC, hematological indices, oxidant/antioxidant markers and PFT values included; force vital capacity (FVC) and peak expiratory flow (PEF) were assessed at the beginning (step 0), one and two month (step I and II, respectively) after starting treatment. RESULTS: Total and different white blood cell in Zat 5 and 10 mg/kg treated groups in Step I and II were significantly decreased compared to Step 0 (p < 0.05 to p < 0.001). The levels of thiol, superoxide dismutase (SOD) and catalase (CAT) in Zat 5 and 10 mg/kg treated groups in step I and II were significantly increased (p < 0.05 to p < 0.001) but the level of malondialdehyde (MDA) significantly decreased in two treatment groups compared to Step 0 (p < 0.05 and p < 0.001 respectively). FVC and PEF values were significant increase in Zat 5 and 10 mg/kg treated groups in step I and II compared to step 0 (p < 0.05 to p < 0.001). Furthermore, FVC and PEF values in Zat 5 mg/kg were also increased in step II compared to step I (p < 0.01 for both). The percentage improvement of total and differential WBC, oxidant/antioxidant markers, FVC and PEF values during two moth treatment period significantly improved in the treated groups compared to the placebo group. CONCLUSION: Z. multiflora reduces inflammatory cells and oxidant biomarkers, while increase antioxidant biomarkers and improved PFT tests in SM exposed patients in a two moth treatment period.

Ocular Effects of Sulfur Mustard and Therapeutic Approaches.

Sulfur mustard (SM) is a strong blistering, highly reactive, lipophilic chemical war agent that causes injury in different organs including the skin, eyes, and respiratory tract. The Eyes are especially susceptible to the consequences of SM poisoning because of the aqueous and mucosal nature of conjunctiva and cornea. DNA alkylation and depletion of glutathione, are the most important mechanisms of SM action in the eye injuries. Acute clinical symptoms are including decrease in visual acuity, dryness, photophobia, blepharospasm, conjunctivitis, and complaints of foreign body sensation and soreness that gradually progress to severe ocular pain. Corneal abrasions, ulcerations, vesication, and perforations are common corneal consequences in SM injured victims. Appearance of chronic symptoms has been reported as chronic inflammation of the corneal and conjunctival vasculature, ischemia, lipid and cholesterol deposition, scarring in cornea, corneal thinning, opacification and perforation of the cornea, limbal stem cell deficiency (LSCD), and neovascularization. Different medical and surgical protocols have been documented in the management of SM-induced ocular injuries, including preservative-free artificial tears, topical steroids and antibiotic, mydriatic, antiglaucoma drops, therapeutic contact lenses, dark glasses and punctal plugs/cauterization, N-acetylcysteine, tarsorrhaphy, amniotic membrane transplantation, stem cell transplantation, and corneal transplantation. New drugs such as resolvin E1, topical form of essential fatty acids, thymosin ß4, 43 amino-acid polypeptides, topical form of curcumin, newly formulated artificial tears, diquafosol, rebamipide, tretinoin, and oral uridineseems to be beneficial in the management of ocular lesion associated with sulfur mustard poisoning. Further studies are needed to approve these drugs in SM victims. J. Cell. Biochem. 118: 3549-3560, 2017. © 2017 Wiley Periodicals, Inc.

Efficacy of probiotic supplementation on quality of life and pulmonary symptoms due to sulfur mustard exposure: a randomized double-blind placebo-controlled trial.

OBJECTIVE: This study investigated the efficacy and safety of supplementation with probiotics in improving chronic pulmonary symptoms due to sulfur mustard (SM) exposure. METHODS: In a randomized double-blind placebo-controlled study, 65 subjects suffering from chronic pulmonary complications of SM were assigned to one probiotic capsule (1 × 109 CFU containing seven strains of lactic acid-producing bacteria) every 12 h or an identical placebo for six weeks. Serum high-sensitivity C-reactive protein (CRP) concentrations, pulmonary function tests (FEV1, FEV1/FVC and MMEF 25-75%) and COPD assessment test (CAT) were assessed at baseline and at the end of trial. RESULTS: The groups were comparable in baseline characteristics. There were significant improvements in FEV1/FVC in the probiotic but not in placebo group. CAT scores were decreased in both study groups. However, between-group comparison of changes in the assessed parameters reached statistical significance only for CAT score (p < 0.001). There was no report of adverse events during the course of trial. CONCLUSIONS: Findings of the present trial favor the efficacy of probiotic supplementation in improving the pulmonary symptoms of SM-exposed subjects.

Caffeic acid, morin hydrate and quercetin partially attenuate sulfur mustard-induced cell death by inhibiting the lipoxygenase pathway.

Sulfur mustard (SM) is an alkylating agent, which has been used as in chemical warfare in a number of conflicts. As the generation of reactive oxygen species (ROS), and adducts in DNA and proteins have been suggested as the mechanism underlying SM­induced cytotoxicity, the present study screened several antioxidant candidates, including tannic acid, deferoxamine mesylate, trolox, vitamin C, ellagic acid and caffeic acid (CA) to assess their potential as therapeutic agents for SM­induced cell death. Among several antioxidants, CA partially alleviated SM­induced cell death in a dose­dependent manner. Although CA treatment decreased the phosphorylation of p38 mitogen­activated protein (MAP) kinase and p53, p38 MAP kinase inhibition by SB203580 did not affect SM­induced cell death. As CA has also been reported as a 15­lipoxygenase (15­LOX) inhibitor, the role of 15­LOX in SM­induced cytotoxicity was also examined. Similar to the results observed with CA, treatment with PD146176, a specific 15­LOX inhibitor, decreased SM­induced cytotoxicity, accompanied by decreases in the production of tumor necrosis factor­α and 15­hydroxyeicosatetraenoic acid. Furthermore, the present study investigated the protective effects of two natural 15­LOX inhibitors, morin hydrate and quercetin, in SM­induced cytotoxicity. As expected, these inhibitors had similar protective effects against SM­induced cytotoxicity. These antioxidants also reduced the generation of ROS and nitrate/nitrite. Therefore, the results of the present study indicated that the natural products, CA, quercetin and morin hydrate, offer potential as adjuvant therapeutic agents for SM­induced toxicity, not only by reducing inflammation mediated by the p38 and LOX signaling pathways, but also by decreasing the generation of ROS and nitrate/nitrite.

Early indicators of survival following exposure to mustard gas: Protective role of 25(OH)D.

The use of sulfur mustard (SM) as a chemical weapon for warfare has once again assumed center stage, endangering civilian and the military safety. SM causes rapid local skin vesication and late-onset systemic toxicity. Most studies on SM rely on obtaining tissue and blood for characterizing burn pathogenesis and assessment of systemic pathology, respectively. However the present study focuses on developing a non-invasive method to predict mortality from high dose skin SM exposure. We demonstrate that exposure to SM leads to a dose dependent increase in wound area size on the dorsal surface of mice that is accompanied by a progressive loss in body weight loss, blood cytopenia, bone marrow destruction, and death. Thus our model utilizes local skin destruction and systemic outcome measures as variables to predict mortality in a novel skin-based model of tissue injury. Based on our recent work using vitamin D (25(OH)D) as an intervention to treat toxicity from SM-related compounds, we explored the use of 25(OH)D in mitigating the toxic effects of SM. Here we show that 25(OH)D offers protection against SM and is the first known demonstration of an intervention that prevents SM-induced mortality. Furthermore, 25(OH)D represents a safe, novel, and readily translatable potential countermeasure following mass toxic exposure.

Effects of Curcuminoids-Piperine Combination on Systemic Oxidative Stress, Clinical Symptoms and Quality of Life in Subjects with Chronic Pulmonary Complications Due to Sulfur Mustard: A Randomized Controlled Trial.

Oxidative stress plays a key role in the development of chronic pulmonary complications of sulfur mustard (SM). Curcuminoids are polyphenols with documented safety and antioxidant activity. The present study aimed to investigate the efficacy of short-term supplementation with curcuminoids (co-administered with piperine to enhance the bioavailability of curcuminoids) in alleviating systemic oxidative stress and clinical symptoms, and improvement of health-related quality of life (HRQoL) in subjects suffering from chronic pulmonary complications due to SM exposure who are receiving standard respiratory treatments. Eighty-nine subjects were recruited to this randomized double-blind placebo-controlled trial, being randomly allocated to either curcuminoids (1500 mg/day) + piperine (15 mg/day) combination (n = 45) or placebo (n = 44) for a period of 4 weeks. High-resolution computed tomography suggested the diagnosis of bronchiolitis obliterans in all subjects. Efficacy measures were changes in serum levels of reduced glutathione (GSH) and malonedialdehyde (MDA). The severity and frequency of respiratory symptoms and HRQoL were also assessed using St. George respiratory Questionnaire (SGRQ) and COPD Assessment Test (CAT) indices. Serum levels of GSH were increased whilst those of MDA decreased by the end of trial in both groups. Likewise, there were significant improvements in the total as well as subscale (symptoms, activity and impact) SGRQ and CAT scores in both groups. However, comparison of magnitude of changes revealed a greater effect of curcuminoids-piperine combination compared to placebo in elevating GSH, reducing MDA and improving CAT and SGRQ (total and subscale) scores (p < 0.001). Regarding the promising effects of curcuminoids on the measures of systemic oxidative stress, clinical symptoms and HRQoL, these phytochemicals may be used as safe adjuvants in patients suffering from chronic SM-induced pulmonary complications who are receiving standard treatments.

Selection of non-steroidal anti-inflammatory drug and treatment regimen for sulfur mustard-induced cutaneous lesions.

The inflammatory process plays an important role in sulfur mustard (HD) injury and HD pathogenesis, suggesting that anti-inflammatory treatments applied as soon as possible following HD injury may reduce tissue damage and accelerate healing. This study used the HD dermal weanling swine model to investigate the efficacy of two non-steroidal anti-inflammatory drugs, capsaicin and diclofenac, when applied in combination with the steroid, clobetasol. The therapeutic regimen was also investigated with respect to initiation of treatment post-exposure, frequency and duration. Yorkshire-cross pigs were randomly assigned to experimental groups, corresponding to all combinations of treatment (capsaicin with clobetasol or diclofenac with clobetasol), onset time (1, 2 or 4 h post-exposure), treatment duration (1, 3 or 5 days) and frequency of applications (2, 3 or 4 per day). For each animal, two sites on the ventral abdomen were exposed to 400 µL of neat HD for 8 min to achieve superficial dermal (SD) lesions and two sites were exposed to 400 µL neat HD for 30 min to achieve deep dermal (DD) lesions. Each treatment regimen was tested against a SD and a DD injury. Untreated SD and DD lesion sites served as within-animal controls. Assessments, up to one week post-challenge, included digital photographs, clinical assessments (lesion size measurements and modified Draize scoring), transepidermal water loss (TEWL), reflectance colorimetry and histopathologic evaluations that included an estimate for depth of injury and wound healing parameters. Diclofenac plus clobetasol treatment resulted in significant reductions in lesion contracture and modified Draize scores, increased barrier function (decreased TEWL), and increased healing as determined by histopathology for both SD and DD injury when compared with untreated sites and sites treated with capsaicin plus clobetasol. An increased duration of treatment from 1 to 5 days was most commonly associated with decreased clinical assessment and histopathological severity scores. Therefore, a combination of diclofenac and clobetasol application, when administered for at least five days, shows promise in ameliorating HD-induced lesions.

[Long-term complications of sulfur mustard exposure: a therapeutic update].

Sulfur mustard (SM) is an alkylating chemical warfare agent with high military significance due to its high toxicity, resistance and availability. SM was widely used in military conflicts, the last being the Iran-Iraq war with more than 100,000 Iranians exposed, one-third of whom are still suffering from late effects. The intensity of the delayed complications correlates to the extent, the area and the route of exposure. The clinical manifestations most commonly involve respiratory, ocular and dermal effects. Respiratory complications include dyspnea, cough and expectorations and various obstructive and restrictive lung diseases. Dermal complications are itching, burning sensation, blisters, dry skin, dermatitis and pigmentary changes. Ocular complications include photophobia, red eye, tearing, corneal ulcers and blindness. Although the picture remains incomplete the major mechanisms responsible for the clinical and pathological effects of SM are: DNA alkylation and cross-linking, protein modification and membrane damage in addition to induction of inflammatory mediators in the target tissues causing extensive necrosis, apoptosis and loss of tissue structure. The current report reviews long-term complications of SM exposure, focusing on new treatments tested in clinical trials conducted on humans. Such treatments include: N-acetyl cysteine, bronchodilators, corticosteroids, Interferon-gamma, furosemide and morphine for the respiratory complications. Ocular complications may entail: Invasive procedures treating corneal complication, limbal ischemia and stem cell deficiency. Treatment for dermatological complications include: anti-depressants, pimercrolimus, Unna's boot, capsaicin, phenol and menthol, Aloe vera and olive oil, curcumin and Interferon-gamma.

A novel decontaminant and wound healant formulation of N,N'-dichloro-bis[2,4,6-trichlorophenyl]urea against sulfur mustard-induced skin injury.

Sulfur mustard (SM)-induced dermatotoxicity can be prevented by an immediate use of decontamination agents. However, practically due to the time lapse between decontamination and exposure, there is always a possibility of wound formation. In view of this, a hydrophilic decontamination formulation of CC-2 (DRDE/WH-03) was fortified with Aloe vera gel and betaine (DRDE/WH-01) for improving its wound healing ability. Swiss albino mice were exposed to SM percutaneously (5 mg/kg) once, and after 24 hours, DRDE/WH-01, DRDE/WH-03, framycetin, and aloe gel were applied topically, daily for 7 days. Skin sections were subjected to histopathology, histomorphologic grading, tissue leukocytosis, and immunohistochemistry of inflammatory-reparative biomarkers on 3 and 7 days, respectively. DRDE/WH-01, framycetin, and aloe gel showed better reepithelialization, angiogenesis, and fibroplasia compared with DRDE/WH-03 and SM control. On the basis of histomorphologic scale, DRDE/WH-01, framycetin, and aloe gel were found to be equally efficacious. Up-regulation of interleukin-6 and infiltrating leukocytes, endothelial nitric oxide synthase and angiogenesis, fibroblast growth factor, and transforming growth factor-alpha with fibroplasia and reepithelialization were well correlated at various stages of the healing process. DRDE/WH-01 was equally effective as framycetin and has shown improved wound healing efficacy compared with DRDE/WH-03. Thus, DRDE/WH-01 can be recommended as a universal decontaminant and wound healant against vesicant-induced skin injury.

Silibinin as a potential therapeutic for sulfur mustard injuries.

Sulfur mustard (SM) is a vesicating chemical warfare agent causing skin blistering, ulceration, impaired wound healing, prolonged hospitalization and permanent lesions. Silibinin, the lead compound from Silybum marianum, has also been discussed as a potential antidote to SM poisoning. However, its efficacy has been demonstrated only with regard to nitrogen mustards. Moreover, there are no data on the efficacy of the water-soluble prodrug silibinin-bis-succinat (silibinin-BS). We investigated the effect of SIL-BS treatment against SM toxicity in HaCaT cells with regard to potential reduction of necrosis, apoptosis and inflammation including dose-dependency of any protective effects. We also demonstrated the biotransformation of the prodrug into free silibinin. HaCaT cells were exposed to SM (30, 100, and 300µM) for 30min and treated thereafter with SIL-BS (10, 50, and 100µM) for 24h. Necrosis and apoptosis were quantified using the ToxiLight BioAssay and the nucleosome ELISA (CDDE). Pro-inflammatory interleukins-6 and -8 were determined by ELISA. HaCaT cells, incubated with silibinin-BS were lysed and investigated by LC-ESI MS/MS. LC-ESI MS/MS results suggest that SIL-BS is absorbed by HaCaT cells and biotransformed into free silibinin. SIL-BS dose-dependently reduced SM cytotoxicity, even after 300µM exposure. Doses of 50-100µM silibinin-BS were required for significant protection. Apoptosis and interleukin production remained largely unchanged by 10-50µM silibinin-BS but increased after 100µM treatment. Observed reductions of SM cytotoxicity by post-exposure treatment with SIL-BS suggest this as a promising approach for treatment of SM injuries. While 100µM SIL-BS is most effective to reduce necrosis, 50µM may be safer to avoid pro-inflammatory effects. Pro-apoptotic effects after high doses of SIL-BS are in agreement with findings in literature and might even be useful to eliminate cells irreversibly damaged by SM. Further investigations will focus on the protective mechanism of silibinin and its prodrug and should establish an optimum concentration for treatment.

Silibinin, dexamethasone, and doxycycline as potential therapeutic agents for treating vesicant-inflicted ocular injuries.

There are no effective and approved therapies against devastating ocular injuries caused by vesicating chemical agents sulfur mustard (SM) and nitrogen mustard (NM). Herein, studies were carried out in rabbit corneal cultures to establish relevant ocular injury biomarkers with NM for screening potential efficacious agents in laboratory settings. NM (100nmol) exposure of the corneas for 2h (cultured for 24h), showed increases in epithelial thickness, ulceration, apoptotic cell death, epithelial detachment microbullae formation, and the levels of VEGF, cyclooxygenase-2 (COX-2) and matrix metalloproteinase-9 (MMP-9). Employing these biomarkers, efficacy studies were performed with agent treatments 2h and every 4h thereafter, for 24h following NM exposure. Three agents were evaluated, including prescription drugs dexamethasone (0.1%; anti-inflammatory steroid) and doxycycline (100nmol; antibiotic and MMP inhibitor) that have been studied earlier for treating vesicant-induced eye injuries. We also examined silibinin (100µg), a non-toxic natural flavanone found to be effective in treating SM analog-induced skin injuries in our earlier studies. Treatments of doxycycline+dexamethasone, and silibinin were more effective than doxycycline or dexamethasone alone in reversing NM-induced epithelial thickening, microbullae formation, apoptotic cell death, and MMP-9 elevation. However, dexamethasone and silibinin alone were more effective in reversing NM-induced VEGF levels. Doxycycline, dexamethasone and silibinin were all effective in reversing NM-induced COX-2 levels. Apart from therapeutic efficacy of doxycycline and dexamethasone, these results show strong multifunctional efficacy of silibinin in reversing NM-induced ocular injuries, which could help develop effective and safe therapeutics against ocular injuries by vesicants.

Efficacy of Aloe vera/olive oil cream versus betamethasone cream for chronic skin lesions following sulfur mustard exposure: a randomized double-blind clinical trial.

BACKGROUND: Chronic pruritic skin lesions are among the common late complications of sulfur mustard intoxication. In the present randomized double-blind clinical trial, therapeutic efficacy of Aloe vera/olive oil combination cream in the alleviation of these lesions was evaluated and compared to that of betamethasone 0.1% cream. METHODS: Sixty-seven Iranian chemical warfare-injured veterans were randomized to apply A. vera/olive oil (n=34, completers=31) or betamethasone 0.1% (n=33, completers=32) cream twice daily for 6 weeks. Evaluation of pruritus severity was performed using a pruritic score questionnaire and visual analogue scale (VAS). RESULTS: Both treatments were associated with significant reductions in the frequency of pruritus (p<0.05), burning sensation (p<0.01 and p<0.001 in A. vera/olive oil and betamethasone group, respectively), scaling (p<0.01 and p<0.05) and dry skin (p<0.001) at the end of trial. Fissure and excoriation were only reduced in the A. vera group (p<0.05). The change in the frequency of hyper- and hypopigmentation lesions, blisters, erythema and lichenification did not reach statistical significance in any of the groups (p>0.05). Mean pruritus (p<0.05) and VAS scores (p<0.01 and p<0.05) were significantly decreased by the end of trial in both groups. The rate of improvement in the pruritus severity [defined as being classified in a less severe category (mild, moderate and severe)] was found to be comparable between the groups (p>0.05). CONCLUSION: A. vera/olive oil cream was at least as effective as betamethasone 0.1% in the treatment of sulfur mustard-induced chronic skin complications and might serve as a promising therapeutic option for the alleviation of symptoms in mustard gas-exposed patients.

Improvement of sulphur mustard-induced chronic pruritus, quality of life and antioxidant status by curcumin: results of a randomised, double-blind, placebo-controlled trial.

Skin is among the first and most heavily damaged organs upon sulphur mustard (SM) exposure. Pruritus is the most common chronic skin complication of SM, which adversely affects the quality of life (QoL). However, current therapies for the management of SM-induced pruritus are very limited and associated with side effects. The present trial investigated the efficacy of curcumin in the alleviation of SM-induced chronic pruritic symptoms. A total of ninety-six male Iranian veterans (age 37-59 years) were randomised to receive either curcumin (1 g/d, n 46) or placebo (n 50) for 4 weeks. Serum concentrations of substance P and activities of antioxidant enzymes were measured at baseline and at the end of the trial. Assessment of pruritus severity was performed using the pruritus score, visual analogue scale (VAS) and scoring atopic dermatitis (SCORAD) index. QoL was evaluated using the Dermatology Life Quality Index (DLQI) questionnaire. Serum concentrations of substance P (P<0·001) as well as activities of superoxide dismutase (P=0·02), glutathione peroxidase (P=0·006) and catalase (P<0·001) were significantly reduced in the curcumin group, while no significant change was observed in the placebo group. Curcumin supplementation was also associated with significant reductions in measures of pruritus severity including the pruritus score (P<0·001), VAS score (P<0·001), overall (P<0·001) and objective SCORAD (P=0·009), and DLQI's first question (P<0·001). None of these measures was significantly changed in the placebo group. As for the QoL, although DLQI scores decreased in both groups (P<0·001 and P=0·003 in the curcumin and placebo groups, respectively), the magnitude of reduction was significantly greater in the curcumin group (P<0·001). In conclusion, curcumin may be regarded as a natural, safe, widely available and inexpensive treatment for the management of SM-induced chronic pruritus.

Evaluation of wound-healing formulation against sulphur mustard-induced skin injury in mice.

Sulphur mustard (SM) is a bifunctional alkylating agent that causes cutaneous blisters in human and animals. Remedies to SM-induced dermatotoxicity are still in experimental stage. Due to inevitable requirement of a wound-healing formulation against SM-induced skin lesions, efficacy of formulations including povidone iodine, Aloe vera gel, betaine or framycetin sulphate was evaluated in present study. SM was applied percutaneously (5 mg/kg) once on back region of Swiss albino mice; and after 24 hours, DRDE/WH-02 (Defence Research and Development Establishment/ Wound Healant- 02, containing polyvinylpyrrolidone [PVP], A. vera gel and betaine), Ovadine, Soframycin or A. vera gel were applied topically, daily for 3 or 7 days in different groups. Skin sections were subjected to histopathology, histomorphologic grading, tissue leukocytosis, terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL) assay and immunohistochemistry of inflammatory-reparative biomarkers. DRDE/WH-02 treated mice received highest score on the basis of histomorphologic scale and lowest number of TUNEL-positive cells compared to other groups. DRDE/WH-02 showed better wound healing as evidenced by widespread re-epithelialization, homogenous fibroplasias well supported by the expression of transforming growth factor-α, endothelial nitric oxide synthase (eNOS) and fibroblast growth factor. Upregulation of interleukin 6 in DRDE/WH-02-treated mice skin resulted in increased tissue leukocytosis and an early removal of tissue debris that initiated reparative process at faster rate compared to other groups. In conclusion, DRDE/WH-02 provided better healing effect and can be recommended as an effective wound healant against SM-induced skin injury.

The effect of Nigella sativa alone, and in combination with dexamethasone, on tracheal muscle responsiveness and lung inflammation in sulfur mustard exposed guinea pigs.

UNLABELLED: ETHNOMEDICAL RELEVANCE: The anti-inflammatory activity of both systemic and local administrations of essential oil from Nigella sativa L. has been shown. AIM OF THE STUDY: Therefore, the effect of Nigella sativa on tracheal responsiveness (TR) and lung inflammation of sulfur mustard (SM) exposed guinea pigs was examined. MATERIALS AND METHODS: Guinea pigs were exposed to diluent solution (control group), inhaled SM (SME group), SME treated with Nigella sativa (SME+N), SME treated with dexamethasone (SME+D) and SME treated with both drugs (SME+N+D), (n=7 for each group). TR to methacholine, total white blood cell (WBC) and differential WBC count of lung lavage, and serum cytokines were measured 14 days post-exposure. RESULTS: The values of TR, eosinophil, monocyte, lymphocyte, interleukine-4 (IL-4) and interferon gamma (IFN-γ) of SME group were significantly higher than those of controls (p<0.05 to p<0.001). The TR in SME+N, SME+D and SME+N+D was significantly lower compared to that of SME group (p<0.01 for all cases). The percentage of eosinophil in SME+D, and the percentage of monocyte in SME+N+D (p<0.05 to p<0.01) were significantly lower than those in SME group. The neutrophil number was decreased in SME+N and SME+N+D groups compared to SME animals (p<0.05 to p<0.01). IL-4 levels in serum of SME+N (p<0.01), SME+D (p<0.05), SME+N+D (p<0.01) and IFN-γ in SME+N (p<0.05) were greater than those in SME animals. CONCLUSIONS: These results showed a preventive effect of Nigella sativa on TR and lung inflammation of SM exposed guinea pigs.