Diabetes and acute bacterial skin and skin structure infections.

Acute bacterial skin and skin structures infections (ABSSSIs) are associated with high morbidity, costs and mortality in patients with diabetes mellitus. Their appropriate management should include several figures and a well-organized approach. This review aims to highlight the interplay between diabetes and ABSSSIs and bring out the unmet clinical needs in this area. Pathogenetic mechanisms underlying the increased risk of ABSSSIs in diabetes mellitus are multifactorial: high glucose levels play a crucial pathogenetic role in the tissue damage and delayed clinical cure. Moreover, the presence of diabetes complications (neuropathy, vasculopathy) further complicates the management of ABSSSIs in patients with diabetes. Multidrug resistance organisms should be considered in this population based on patient risk factors and local epidemiology and etiological diagnosis should be obtained whenever possible. Moreover, drug-drug interactions and drug-related adverse events (such as nephrotoxicity) should be considered in the choice of antibiotic therapy. Reducing unnecessary hospitalizations and prolonged length of hospital stay is of primary importance now, more than ever. To achieve these objectives, a better knowledge of the interplay between acute and chronic hyperglycemia, multidrug resistant etiology, and short and long-term outcome is needed. Of importance, a multidisciplinary approach is crucial to achieve full recovery of these patients.

Clinical spectrum of Lyme disease.

Lyme disease (borreliosis) is one of the most common vector-borne diseases worldwide. Its incidence and geographic expansion has been steadily increasing in the last decades. Lyme disease is caused by Borrelia burgdorferi sensu lato, a heterogeneous group of which three genospecies have been systematically associated to Lyme disease: B. burgdorferi sensu stricto Borrelia afzelii and Borrelia garinii. Geographical distribution and clinical manifestations vary according to the species involved. Lyme disease clinical manifestations may be divided into three stages. Early localized stage is characterized by erythema migrans in the tick bite site. Early disseminated stage may present multiple erythema migrans lesions, borrelial lymphocytoma, lyme neuroborreliosis, carditis, or arthritis. The late disseminated stage manifests with acordermatitis chronica atrophicans, lyme arthritis, and neurological symptoms. Diagnosis is challenging due to the varied clinical manifestations it may present and usually involves a two-step serological approach. In the current review, we present a thorough revision of the clinical manifestations Lyme disease may present. Additionally, history, microbiology, diagnosis, post-treatment Lyme disease syndrome, treatment, and prognosis are discussed.

Successful Management of Infected Facial Filler with Brucella.

BACKGROUND: The widespread desire to maintain youth and beauty with minimally invasive procedures made the use of soft tissue fillers an attractive option to correct numerous aesthetic problems. However, many complications have emerged recently especially with the use of non-FDA-approved permanent materials. In this case report, we are demonstrating the effective management of a patient with Brucella isolated from a facial abscess at the site of prior permanent filler injection done 17 years ago. METHODS: A 56-year-old woman presented complaining of painful swelling of the right cheek after a failed trial of filler evacuation and intralesional corticosteroid injection. The patient was interviewed carefully, and physical examination was performed, followed by culture and imaging. RESULTS: The patient had a facial abscess that was complicated by parotid infiltration by Brucella. Eventually she was managed successfully by anti-Brucella antibiotics for 6 months with no further complaints. A review of causative organisms in the literature along with recommendations for management is discussed. CONCLUSION: Permanent fillers have shown many complications that can occur even years after injection. Therefore, physicians should be careful when using permanent fillers and should restrict their use to certain situations. Moreover, rare infections must be kept in mind and careful history, including travel history and animal contact, needs to be considered particularly in the unusual scenarios. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Tattoos: Evaluation of knowledge about health complications and their prevention among students of Tricity universities.

INTRODUCTION: Tattooing is a very popular form of body modification among young people. However, this kind of procedure entails the risk of various health complications. The objective of the study was to evaluate the students' knowledge about contraindications, complications, and health risks that skin tattooing may cause. Additionally, the purpose of the study was to assess how the profile of education (medical vs nonmedical) impacts on the knowledge of the respondents. METHODS: We surveyed a group of 1199 people, of which 326 (27%) had tattoos. The base of the study is an anonymously filled, author's online survey consisting of 25 questions. RESULTS: Eighty six percent of the students from the Medical University of Gdansk indicated the risk of HCV virus infection during tattooing, while only 34% of students from other Tricity universities were aware of this danger. Sixty seven percent of people with tattoos felt that having them does not affect any diagnostic and therapeutic procedures. Most of respondents mentioned the tattoo artist (79%) and the Internet (73%) as a source of information before having a tattoo, while only 5% and 8% respondents asked a doctor or read medical literature about it. Fourty nine percent of respondents reported that before the procedure, tattooist failed to ask them about their health condition and medications. CONCLUSIONS: Knowledge of students about safety, contraindications, and complications associated with the performance of tattooing is insufficient. As a result, a need for a better education on the topic for both people who are getting tattoos and tattooists appears evident.

Mycobacterium marinum remains an unrecognized cause of indolent skin infections.

We identified 5 patients who had cutaneous lesions with cultures that yielded Mycobacterium marinum. It was discovered that all 5 patients had a home aquarium, and infection was preceded by trauma to the hand. However, the association between the development of the infection and exposure of the trauma site to the aquarium was not initially established until repeated questioning was performed. Skin biopsies or incision and drainage were performed for all patients, and the diagnosis was established by culture of the specimens. The mean time from initial presentation to diagnosis and initiation of appropriate treatment was 91 days (range, 21-245 days). Prolonged therapy for 2 to 6 months was necessary for resolution of the infection.

Host-microbe interactions: Malassezia and human skin.

The skin is our first line of defense, protecting us from invasion and evaporation. Its variable structure, changing geography, and complex immune repertoire provide a vast interface for our cutaneous microbial community. Skin is inhabited by many thousands of microbes, but this review focuses on the dominant eukaryote, Malassezia, and its host interaction. Malassezia compromises 17 species with variable niche specificities and differing pathogenic potential. It has been known as a skin inhabitant for over 100 years, and is now accepted to be on all warm-blooded animals. Malassezia occupy healthy and diseased skin, so their role as commensal or pathogenic organisms is complex. Malassezia interact with their host indirectly through immune interplay and directly via chemical mediators. While some interactions are known, many remain to be fully understood.

Structural and functional changes in the microcirculation of lepromatous leprosy patients - Observation using orthogonal polarization spectral imaging and laser Doppler flowmetry iontophoresis.

Leprosy is a chronic granulomatous infection of skin and peripheral nerves caused by Mycobacterium leprae and is considered the main infectious cause of disability worldwide. Despite the several studies regarding leprosy, little is known about its effects on microvascular structure and function in vivo. Thus, we have aimed to compare skin capillary structure and functional density, cutaneous vasomotion (spontaneous oscillations of arteriolar diameter), which ensures optimal blood flow distribution to skin capillaries) and cutaneous microvascular blood flow and reactivity between ten men with lepromatous leprosy (without any other comorbidity) and ten age- and gender-matched healthy controls. Orthogonal polarization spectral imaging was used to evaluate skin capillary morphology and functional density and laser Doppler flowmetry to evaluate blood flow, vasomotion and spectral analysis of flowmotion (oscillations of blood flow generated by vasomotion) and microvascular reactivity, in response to iontophoresis of acetylcholine and sodium nitroprusside. The contribution of different frequency components of flowmotion (endothelial, neurogenic, myogenic, respiratory and cardiac) was not statistically different between groups. However, endothelial-dependent and -independent vasodilatations elicited by acetylcholine and sodium nitroprusside iontophoresis, respectively, were significantly reduced in lepromatous leprosy patients compared to controls, characterizing the existence of microvascular dysfunction. These patients also presented a significant increase in the number of capillaries with morphological abnormalities and in the diameters of the dermal papilla and capillary bulk when compared to controls. Our results suggest that lepromatous leprosy causes severe microvascular dysfunction and significant alterations in capillary structure. These structural and functional changes are probably induced by exposure of the microvascular bed to chronic inflammation evoked by the Mycobacterium leprae.

Common Skin Conditions in Children: Skin Infections.

Skin infections account for a significant subset of dermatologic conditions of childhood. Common cutaneous viral infections in children include warts, molluscum contagiosum, hand-foot-and-mouth disease, and herpes simplex. Although viral infections are self-limited and often only mildly symptomatic, they can cause anxiety, embarrassment, and health care use. Recognition of their common and atypical presentations is necessary to differentiate them from other skin conditions of similar morphology. Impetigo, cellulitis, and abscess comprise the majority of childhood bacterial skin infections and are treated with topical or systemic antibiotics that cover group A Streptococcus and Staphylococcus aureus. Common fungal dermatologic infections in children are oral and genital candidiasis, tinea capitis, and tinea corporis. Management consists of topical and systemic antifungals, including nystatin, triazoles, terbinafine, griseofulvin, and imidazoles. Scabies is the most common parasitic skin infection among children and is managed with topical permethrin. Although serious illness is not common among children returning from international travel, patients presenting with fever and rash, especially petechial or hemorrhagic lesions, require thorough evaluation. Of the numerous reportable conditions that present with childhood rash, tick-borne illnesses, measles, rubella, and varicella are the most common.

Factors shaping the composition of the cutaneous microbiota.

From birth, we are constantly exposed to bacteria, fungi and viruses, some of which are capable of transiently or permanently inhabiting our different body parts as our microbiota. The majority of our microbial interactions occur during and after birth, and several different factors, including age, sex, genetic constitution, environmental conditions and lifestyle, have been suggested to shape the composition of this microbial community. Propionibacterium acnes is one of the most dominant lipophilic microbes of the postadolescent, sebum-rich human skin regions. Currently, the role of this bacterium in the pathogenesis of the most common inflammatory skin disease, acne vulgaris, is a topic of intense scientific debate. Recent results suggest that Westernization strongly increases the dominance of the Propionibacterium genus in human skin compared with natural populations living more traditional lifestyles. According to the disappearing microbiota hypothesis proposed by Martin Blaser, such alterations in the composition of our microbiota are the possible consequences of socioeconomic and lifestyle changes occurring after the industrial revolution. Evanescence of species that are important elements of the human ecosystem might lead to the overgrowth and subsequent dominance of others because of the lack of ecological competition. Such changes can disturb the fine-tuned balance of the human body and, accordingly, our microbes developed through a long co-evolutionary process. These processes might lead to the transformation of a seemingly harmless species into an opportunistic pathogen through bacterial dysbiosis. This might have happened in the case of P. acnes in acne pathogenesis.

RNA-Seq Transcriptomic Responses of Full-Thickness Dermal Excision Wounds to Pseudomonas aeruginosa Acute and Biofilm Infection.

Pseudomonas aeruginosa infections of wounds in clinical settings are major complications whose outcomes are influenced by host responses that are not completely understood. Herein we evaluated transcriptomic changes of wounds as they counter P. aeruginosa infection-first active infection, and then chronic biofilm infection. We used the dermal full-thickness, rabbit ear excisional wound model. We studied the wound response: towards acute infection at 2, 6, and 24 hrs after inoculating 106 bacteria into day-3 wounds; and, towards more chronic biofilm infection of wounds similarly infected for 24 hrs but then treated with topical antibiotic to coerce biofilm growth and evaluated at day 5 and 9 post-infection. The wounds were analyzed for bacterial counts, expression of P. aeruginosa virulence and biofilm-synthesis genes, biofilm morphology, infiltrating immune cells, re-epithelialization, and genome-wide gene expression (RNA-Seq transcriptome). This analysis revealed that 2 hrs after bacterial inoculation into day-3 wounds, the down-regulated genes (infected vs. non-infected) of the wound edge were nearly all non-coding RNAs (ncRNAs), comprised of snoRNA, miRNA, and RNU6 pseudogenes, and their down-regulation preceded a general down-regulation of skin-enriched coding gene expression. As the active infection intensified, ncRNAs remained overrepresented among down-regulated genes; however, at 6 and 24 hrs they changed to a different set, which overlapped between these times, and excluded RNU6 pseudogenes but included snRNA components of the major and minor spliceosomes. Additionally, the raw counts of multiple types of differentially-expressed ncRNAs increased on post-wounding day 3 in control wounds, but infection suppressed this increase. After 5 and 9 days, these ncRNA counts in control wounds decreased, whereas they increased in the infected, healing-impaired wounds. These data suggest a sequential and coordinated change in the levels of transcripts of multiple major classes of ncRNAs in wound cells transitioning from inflammation to the proliferation phase of healing.

Bacterial infections of the folds (intertriginous areas).

The axillary, inguinal, post-auricular, and inframammary areas are considered skin folds, where one skin layer touches another. Skin fold areas have a high moisture level and elevated temperature, both of which increase the possibility of microorganism overgrowth. A massive amount of bacteria live on the surface of the skin. Some are purely commensal; thus, only their overgrowth can cause infections, most of which are minor. In some cases, colonization of pathogenic bacteria causes more serious infections. This contribution reviews the bacterial infections of the skin fold areas.

Acute toxicity and risk of infection during total skin electron beam therapy for mycosis fungoides.

BACKGROUND: Detailed rates of acute toxicity and skin infection during total skin electron beam therapy (TSEBT) for mycosis fungoides have not been reported in a large, modern series. OBJECTIVE: We sought to demonstrate the rates of acute toxicity and skin infection during TSEBT. METHODS: We retrospectively reviewed 89 consecutive courses of TSEBT. In all, 82 courses were prescribed a dose of 30 to 36 Gy and were included in the toxicity analysis. We recorded the types and grades of acute treatment toxicities and the incidence of infection during TSEBT for comparison with the previously documented baseline incidence of infection in mycosis fungoides. RESULTS: The most common toxicities included erythema/desquamation (76%), blisters (52%), hyperpigmentation (50%), and skin pain (48%). The worst reported toxicity grade per patient was grade 1 in 21%, grade 2 in 67%, and grade 3 in 10%, with no grade 4 or 5 toxicities. According to the previously reported rate, a total of 2.4 infections were expected for our cohort at baseline. The number with skin infection was 26 (32%) (relative risk 10.8, P < .01), and of these, 12 (15%) were culture confirmed (relative risk 5.0, P < .01). LIMITATIONS: This was a retrospective study design. CONCLUSION: The risk of cutaneous infection is significant during TSEBT.

Complications of injectable fillers, part I.

Dermal filling has rapidly become one of the most common procedures performed by clinicians worldwide. The vast majority of treatments are successful and patient satisfaction is high. However, complications, both mild and severe, have been reported and result from injection of many different types of dermal fillers. In this Continuing Medical Education review article, the author describes common technical errors, the signs and symptoms of both common and rare complications, and management of sequelae in clear, easily adaptable treatment algorithms.

Tannin extracts from immature fruits of Terminalia chebula Fructus Retz. promote cutaneous wound healing in rats.

BACKGROUND: Tannins extracted from immature fruits of Terminalia chebula Fructus Retz. are considered as effective components promoting the process of wound healing. The objective of this study is to explore the optimal extraction and purification technology (OEPT) of tannins, while studying the use of this drug in the treatment of a cutaneous wound of rat as well as its antibacterial effects. METHODS: The content of tannin extracts was measured by the casein method, and antibacterial ability was studied by the micro-dilution method in vitro. In wound healing experiment, animals in group Ⅰ, Ⅱ and Ⅲ were treated with vaseline ointment, tannin extracts (tannin content: 81%) and erythromycin ointment, respectively (5 mg of ointment were applied on each wound). To evaluate the process of wound healing, selected pharmacological and biochemical parameters were applied. RESULTS: After optimal extraction and purification, content of tannin extracts was increased to 81%. Tannin extracts showed the inhibition of Staphylococcus aureus and Klebsiella Pneumonia in vitro. After excision of wounds, on days 7 and 10, the percent of wound contraction of group Ⅱ was higher than that of group Ⅰ. After being hurt with wounds, on days 3, 7, and 10, the wound healing quality of group Ⅱ was found to be better than that of group Ⅰ in terms of granulation formation and collagen organization. After wound creation, on day 3, the vascular endothelial growth factor expression of group Ⅱ was higher than that of group Ⅰ. CONCLUSION: The results suggest that tannin extracts from dried immature fruits of Terminalia chebula Fructus Retz. can promote cutaneous wound healing in rats, probably resulting from a powerful anti-bacterial and angiogenic activity of the extracts.