Recalcitrant dermatophyte infections: identification and risk factors.

INTRODUCTION: Recalcitrant dermatophytosis is an emerging phenomenon that occurs worldwide, and Trichophyton indotineae is currently the prominent cause. MATERIALS AND METHODS: Skin specimens from patients with tinea infection were obtained by scrubbing and then sectioned into three fragments. Two fragments were subjected to direct microscopic examination and culture, while the third portion was utilized in the PCR method. RESULTS: Isolates were morphologically identified as Trichophyton mentagrophytes/interdigitale complex (n = 60 [83.33%]), Microsporum canis (n = 8 [11.11%]), Trichophyton rubrum (n = 3 [4.16%]), and Epidermophyton floccosum (n = 1 [1.38%]). Among 60 T. mentagrophytes complex isolates, 53 (88.33%) were classified as T. indotineae and seven as T. interdigitale genotype II. The disease duration was longer in the T. indotineae group (P = 0.035). Both Gradient PCR and skin-sampling methods yield similar results in terms of positive and negative cases (P = 1.0000). The time patients stopped their medication did not impact the positive case numbers (P = 0.803). Gender had no effects on the frequency (P = 0.699). Familial contamination, dermatologic disorder, and other underlying conditions did not differ in the two group infections (P > 0.05). Steroid usage is strongly associated with the emergence of tinea infection (P < 0.04). The duration of antifungal administration had a substantial effect on the emergence of resistant organisms (P = 0.05). CONCLUSIONS: Steroid usage, T. indotineae involvement, and prolonged exposure to antifungals were the solid and influential factors in recalcitrant involvement. Regarding quick and suitable diagnosis and treatment, which is essential in preventing recalcitrant cases, we suggest that direct skin sample PCR can meet the demands.

Efficacy and safety of date palm leaf-based ointment for treatment of cutaneous warts: A pilot clinical trial.

Despite the considerably high prevalence of cutaneous warts, no optimally effective and safe treatment is available. Leaves of date palm (Phoenix dactylifera L.; Arecaceae) have long been used in Iran's folk medicine as a remedy for warts. To assess the state-of-the-art evidence on using P. dactylifera L. for warts, we conducted a systematic review using CINAHL (via EBSCO), Embase, Medline (via PubMed), ProQuest, Scopus, and Web of Science. We conducted an open-label uncontrolled pilot clinical study to evaluate the efficacy and safety of a proprietary topical date palm leaf-based ointment for the treatment of various types of nongenital warts. This study consisted of an 8-week treatment phase and a 4-week follow-up phase. The assessed outcomes included complete clearance, patient satisfaction (on Likert scale), and the occurrence of any adverse effect. The systematic review demonstrated that the effects of date palm on warts have not been scientifically studied. Thirty patients entered the study with a mean age of 29.5 years (SD = 14.04); among which 17 were female and 13 were male. The patients presented diverse types of warts: verruca vulgaris 15 (50%), plantar 9 (30%), plane 2 (7%), periungual 2 (7%), and warts at multiple sites 2 (7%). In this trial, 19 patients (63.3%) experienced complete clearance and 5 patients (16.6%) experienced partial clearance. Eight patients (26.67%) dropped out during the study. 21 (70%) patients were very satisfied (score on Likert scale = 5) while 1 (3.3%) patient with partial clearance was somewhat satisfied (score on Likert scale = 4). No adverse effect was observed. The results of this pilot study indicate that the date palm leaf-based ointment is a promising treatment whose efficacy and safety should be further investigated in a randomized controlled clinical trial.

Effects of Cosmetic Preservatives on Healthy Facial Skin Microflora.

Objective: The present study was designed to evaluate the effects of seven common preservatives used in Iranian cosmetic products on facial skin microflora. Methods: Fifteen healthy volunteers, aged 20 to 35 years, were recruited. Three symmetrical sites from the cheeks of each volunteer were selected and samples were collected. DNA was extracted from the culture using the boiling method. The fungi's internal transcribed spacer (ITS) region was amplified using ITS1/ITS4 primers, for 16s to identify bacteria and Staphylococcus specific primers. The effects of the preservatives were assessed based on growth on broth culture media. Results: Primary identification was based on yeast on CHROM agar, in which 15 different yeasts were isolated; then, PCR was used to identified the species as: C. albicans (n: 14; 93%), C. orthopsilosis (n: 1; 7%). One primary identified yeast on Dixon media was precisely differentiated as M. furfur using the PCR method. Fifteen primary identified cocci on tryptic soy agar media were identified as Staphylococcus epidermis. All the preservatives showed to inhibit the growth of isolated fungi, but not that of bacterial microflora. Conclusion: The present study showed preservatives in cosmetic products can alter skin microflora while also preventing the growth of pathogenic bacteria.

Evaluation of the safety and efficacy of a biosimilar abobotulinum toxin type A in treating moderate-to-severe glabellar lines: A non-inferiority double blinded randomized controlled trial.

BACKGROUND: Injection of botulinum toxin for cosmetic purposes is a well-established practice. OBJECTIVES: This study was conducted to compare the safety and efficacy of Dyston® (investigational biosimilar abobotulinumtoxinA) with Dysport® (abobotulinumtoxinA, Ipsen) in the treatment of moderate-to-severe glabellar lines. METHODS: Out of 193 screened subjects, 126 volunteers with moderate-to-severe glabellar lines fulfilling eligibility criteria were randomized in a 1:1 ratio to receive either an intramuscular injection of 40-60 units of Dyston® or Dysport® . The primary objective was to test the non-inferiority of Dyston® compared with Dysport® as measured by the percentage of volunteers who achieved no or mild glabellar lines at maximum frown assessed by the physicians based on the Glabellar Line Severity Score (GLSS) at Day 30. Secondary endpoints included the improvement in the glabellar lines at maximum frown and rest states at Days 14, 60, 90, and 120 as well as the side effects of the treatment. RESULTS: Response rates at maximum frown were 75.44% (43/57) in the Dyston® group and 76.67% (46/60) in the Dysport® group on Day 30 (p value: 0.88, 95% CI: -14.24 to 16.70, diff: 1.23) as per-protocol set, and were 75.81% (47/62) and 76.19 (48/63) (p value: 0.96, 95% CI: -14.59 to 15.35, diff: 0.3) in the Dyston® and the Dysport® groups, respectively, based on modified intention to treat population. Adverse events were similar in both groups and mostly mild and well-tolerated. CONCLUSION: Treatment of moderate-to-severe glabellar lines with Dyston® was effective, tolerable, and non-inferior compared with Dysport® .

Skin biophysical assessments of four types of soaps by forearm in-use test.

BACKGROUND: While soaps are the most commonly used cleansing agents for human skin, they also damage the epidermal barrier and potentially increase the risk of disorders such as contact dermatitis. AIMS: This study set out to compare the potential skin irritancy of four types of soaps and their effects on the skin barrier function and biophysical parameters. METHODS: In a nonblinded comparative study, three types of soaps (alkaline, creamy, and glycerin soaps), and a syndet were applied to four different groups of 15 healthy subjects. Subjects washed their left forearm with the respective soap at home at least four times a day for seven days. Biophysical skin parameters, including transepidermal water loss (TEWL), erythema, friction, and pH, were measured at various time points using the Cutometer® MPA 580. RESULTS: After the first wash, a significant increase in TEWL was observed for all groups compared to the pre-intervention period. For the alkaline soap, a substantial increase in pH was observed at all time points compared to the baseline. Syndet, the only acidic soap in this study, showed a significant decrease in pH at the last time compared to all time points. The mean value of erythema was significantly higher in alkaline soap users than glycerin and creamy soap users. CONCLUSION: Our study showed that alkaline-based soaps could cause erythema and increase TEWL and skin pH due to their strong cleansing action, and the addition of compounds such as glycerin can modify these effects. A newer generation of soap containing a mild surfactant such as syndets causes less skin damage.

Activities of Nanoparticles Against Fluconazole-Resistant Candida parapsilosis in Clinical Isolates.

Candida parapsilosis is a non-albicans Candida spp. associated with bloodstream infections in critically ill patients. Failure to treat it effectively due to delay in diagnosis often leads to serious illnessess. The present research aimed to investigate the antifungal activities of nanoparticles (NPs) against fluconazole-resistant C. parapsilosis strains. Ten strains were used from archived clinical isolates. Antifungal activities of NPs were examined based on the Clinical and Laboratory Standards Institute (M27-A3/S4) guideline. The morphological changes of strains exposed to each NP were observed by scanning electron microscope (SEM). The effect of NP on the membrane permeability of C. parapsilosis and the viability of the cells was assessed using the confocal laser scanning microscopy and 3-(4,5-Dimethyl-2-thiazolyl)-2,5-diphenyl-2H-tetrazolium bromide (MTT) assay, respectively. The cytotoxicity was evaluated against three mammalian cell lines. Minimum Inhibitory Concentration of NPs of 10 strains was in the concentration range of 0.5-4 µg/mL; these results were confirmed with the viability test. The antifungal activity of synthesized silver NPs (AgNPs) against resistant C. parapsilosis was greater in comparison with the gold NPs (AuNPs). The SEM images indicated a difference in the fungal morphology of the fungi. The propidium iodide uptake by C. parapsilosis cells showed concentration-dependent mortality in NPs treatment with a confocal laser scanning microscope. There was a notable difference (p < 0.01) in the cell viability in the concentration range of 0.5-4 µg/mL between NPs based on the MTT assay. In addition, these NPs exhibited very low toxicity for three mammalian cell lines, specially at 0.5 µg/mL. AgNPs and AuNPs had fungicidal activities against fluconazole-resistant C. parapsilosis strains. It is crucial to have knowledge based on fundamental research to find new ways to overcome resistant microorganisms.

COVID-19 vaccines: What dermatologists should know?

As COVID-19 vaccination has started worldwide to control this pandemic, dermatologists may face various challenges with these new vaccines. In this manuscript, we review different types of available COVID-19 vaccines and their various production platforms. Vaccination considerations in patients with skin diseases, especially those using immunomodulatory drugs will be presented. Finally, adverse cutaneous reactions of COVID-19 vaccines will be reviewed.

Efficacy and safety of topical spironolactone 5% cream in the treatment of acne: A pilot study.

BACKGROUND: Spironolactone is an effective treatment for female patients with acne vulgaris. However, topical spironolactone could be a valuable treatment option in both male and female acne patients due to the less possibility of systemic side effects with its topical formulation. OBJECTIVE: To evaluate the efficacy and safety of 5% spironolactone cream in the treatment of mild to moderate acne vulgaris. METHODS: In this pilot clinical trial, topical spironolactone 5% was evaluated to treat patients with mild to moderate acne twice a day for 8 weeks. The rate of improvement as any alterations in the number of open and closed comedones, facial inflammatory papules, and acne global grading scores were assessed. Moreover, skin biometric characteristics including skin hydration, erythema, transepidermal water loss (TEWL), pH, sebum, and Propionibacterium acnes bacteria activity were also assessed following the treatment. RESULTS: Fifteen patients participated in our study with a mean age of 25 ± 4.87 years old. A total of 66.6% (n = 10) were female and 33.4% (n = 5) were male. The number of acne papules, open and closed comedones, and acne global grading score decreased significantly 4 and 8 weeks after the beginning of treatment (P < .05). No considerable side effect was reported. Moreover, there was no significant difference between the skin hydration, melanin, erythema, TEWL, pH index, sebum, and P acnes bacteria activity before, 4, and 8 weeks after the treatment with topical spironolactone cream (P > .05). CONCLUSION: The topical 5% spironolactone cream seems to be an effective and safe treatment of acne vulgaris in both male and female patients.

Herbal Therapy for the Management of Seborrheic Dermatitis: A Narrative Review.

INTRODUCTION: Dandruff and Seborrheic Dermatitis (SD) are similar skin conditions with different degrees ofseverity. Since the current therapies cannot remove dandruff efficiently, herbal extracts with better effectiveness and fewer side effects are used in the pharmaceutical and cosmetic industries. Due to the adverse effects of chemical drugs, the use of natural products and traditional medicine has significantly increased over the past few decades. Therefore, in this review, we reported the herbs used as anti-dandruff agents in traditional medicine worldwide. METHODS: The review was conducted on the literature available on the medicinal utility of certain plants as anti-dandruff agents using PubMed and Google Scholar and the following search terms: Dandruff and plants or medicinal plant and dandruff treatment, and essential oil and dandruff. RESULTS: Since the current therapies cannotefficiently remove dandruff, herbal extracts with better effectiveness and fewer side effects are used in the pharmaceutical and cosmetic industries. Nowadays, there are numerous different types of herbal antidandruff shampoos. They are effective and safe without the side effects of chemical agents. Recently, herbal medicine has attracted a great deal of scientific attention. Clinical evidence on the therapeutic effects of herbal products has resulted in the study of far more herbs for their therapeutic roles. CONCLUSION: Herbal therapy plays a significant role in the development of favorable therapeutics, either alone or in combination with conventional antibiotics. However, the major challenges in this regard include finding compounds with satisfactorily lower MICs, low toxicity, and high bioavailability for effective and safe use in humans and animals.

Multidrug-resistant Trichophyton mentagrophytes genotype VIII in an Iranian family with generalized dermatophytosis: report of four cases and review of literature.

BACKGROUND: The global spread of terbinafine-resistant Trichophyton mentagrophytes with point mutations in the squalene epoxidase (SQLE) gene is a big concern. AIM: The present study presents a series of unusual familial cases of generalized dermatophytosis caused by multidrug-resistant T. mentagrophytes genotype VIII. METHODS: Initially, the skin samples of each patient were taken and then subjected to direct microscopy and culture in Mycosel Agar. The molecular identification of Trichophyton species (spp.) was performed for all family members. In addition, the immunologic tests were requested, and an antifungal susceptibility test was carried out using the broth microdilution protocol based on the Clinical and Laboratory Standards Institute M38, third edition. The SQLE gene for a terbinafine-resistant T. mentagrophytes genotype VIII was sequenced and confirmed its nucleotide sequence to KU242352 as a susceptible strain. RESULTS: Based on the results of mycological examination and ITS rDNA sequencing, the etiologic agent was identified as T. mentagrophytes as a zoophilic dermatophyte. This species showed multiple drug resistance in vitro against terbinafine (minimum inhibitory concentration (MICs ≥8 µg/ml), itraconazole (MIC ≥4), and fluconazole (MIC ≥16). The SQLE gene of the isolate was subjected to sequencing for mutation, which showed a point mutation as TTC/TTA in the gene leading to Phe397Leu amino acid substitution in the enzyme. Only one of the family members responded to itraconazole and was cured after the long-term use of itraconazole. Other family members were treated with oral voriconazole with no recurrence. CONCLUSION: The transmission of this resistant T. mentagrophytes to other countries due to globalization is a serious issue to be considered.

Oral Corticosteroid Relieves Post-COVID-19 Anosmia in a 35-Year-Old Patient.

Coronavirus disease 2019 (COVID-19) is a highly infectious respiratory illness caused by SARS-CoV-2. Not much is yet known about this new viral disease. In our early encounter with the COVID-19, before the pandemic and during the early days of dealing with this novel viral disease in our country, we saw some cases of anosmia in patients infected by SARS-CoV-2. In many cases, this chemosensitive dysfunction persisted after the negativization of the nasopharyngeal swab. We report effective treatment of anosmia by oral corticosteroid therapy in a patient recovered from COVID-19.

Evaluation of safety and efficacy of booster injections of hyaluronic acid in improving the facial skin quality.

BACKGROUND: Skin boosting with small particles of hyaluronic acid (HA) is a new method of skin rejuvenation. AIM: Here, we aim to evaluate the efficacy and safety of booster injections of noncross-linked HA in improving the facial skin quality. METHODS: A total of 20 men and women age 40.15 ± 6.63 years were treated with 3 injections of noncross-linked HA (1-2 mL) with intervals of 3 weeks. Skin hydration and elasticity parameters were evaluated before intervention and 1 week and 4 months later. Facial skin improvement also evaluated using physician's global assessment score (PGA). RESULTS: Skin hydration increased 1 week and 4 months after last treatment, (P > .05). Skin firmness (R0) reduced significantly at week 1 and month 4 (P-value = .01 and .00). Skin-tiring effect/fatigue (R3) showed significant decrease at week 1 and month 4 (P-value = .01 and .00, respectively). Four months after last treatment skin gross elasticity (R2) and net elasticity (R5) also increased significantly (P-value = .00). Physician's global assessment 1 week and 4 months after last treatment were 2.33 ± 0.76 and 1.35 ± 0.49 out of 4, respectively. Adverse effects were mostly transient and mild in severity. CONCLUSION: Booster therapy with HA is a safe and well-tolerated procedure, and results in improvement in skin elasticity and relative increase in skin hydration.

Systematic review and meta-analysis of safety and efficacy of high-intensity focused ultrasound (HIFU) for face and neck rejuvenation.

High-intensity focused ultrasound (HIFU) is widely used for skin rejuvenation and tightening. The aim of this study was to determine the safety and efficacy of HIFU for face and neck rejuvenation. A systematic search of peer reviewed articles published before December 2017 was performed using Medline, Web of Science, and Scopus databases. Retrieved studies were screened, and clinical trials or follow-up studies which were evaluated the effect of HIFU on rejuvenation treatments of face and neck area were included. Risk of bias for each study was assessed and was reported. Safety and efficacy variables, which were reported more often in papers, were included in meta-analysis. Seventeen studies involving 477 participants were included in the analysis. Meta-analysis showed moderate improvement as scores of 2.74 (95% CI 2.06-3.43) and 2.68 (95% CI 1.92-3.45), out of 5 maximum score, for objective improvement score and subjective satisfaction score, respectively. Meta-analysis of mean pain score, assessed by a 0-10 Likert score, was 4.2 (95% CI 4.27-5.19). Edema and erythema showed considerable heterogeneity, and no hyperpigmentation was reported by included studies. Included studies used multiple and different outcome variables with different scoring at various time points. Long follow-up was not reported by majority of studies. HIFU is safe procedure in short term and has a moderate effect on rejuvenation of face and neck areas.

Evaluation of Glutathione Reductase and Glutathione Peroxidase in the Serum of Iranian Patients with Alopecia Areata: A Case-control Study.

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Comparison of efficacy and safety of a novel 755-nm diode laser with conventional 755-nm alexandrite laser in reduction of axillary hairs.

The aim of this study was to compare the efficacy and safety of a novel diode system emitting 755 nm wavelength with conventional 755 nm alexandrite laser in skin types III and IV. It was a randomized, right-left comparison, assessor-blind, clinical study. Sixteen female volunteers age 29.52 ± 9.52 were randomly assigned to receive six treatment sessions using 755 nm diode laser on one axilla and 755 nm alexandrite on the opposite axilla. Efficacy was assessed by counting of hairs per square centimeter, 6 months after the last treatment. Treatment outcome was also evaluated by blind reviewing of before and after pictures, using Physician Global Assessment scale (GAS). Subject satisfaction was assessed using visual analogue scale (VAS), pain level and adverse effects were recorded. Skin biophysical parameters (transepidermal water loss, skin sebum, and erythema index) were also measured. Significant reduction in hair count was observed, 6 months after the last treatment session, for both devices (- 33% for 755 nm diode and - 35% for 755 nm alexandrite; p value = 0.85). The mean GAS score was 2.66 for alexandrite treated side vs. 2.00 for diode treated side (p value = 0.036). No severe adverse events were reported. The subject satisfaction score was significantly higher after treatment with alexandrite laser. No significant changes were detected in none of skin biophysical parameters. 755 nm diode laser is suitable for hair removal procedures and it is as effective and safe as the 755 nm alexandrite laser in skin types III-IV.