Antifungal ME1111 in vitro human onychopharmacokinetics.

This study determined ME1111 onychopharmacokinetics and possible topical antifungals' clinical efficacy in human great toenails using an in vitro finite dose model. ME1111 topical formulations in 1, 5, 10 or 15% for 3 days observation and 1, 5 or 10% for 14 days observation, respectively, were used to determine ME1111 penetration rate and transungual kinetics. ME1111 concentrations in the deeper nail (ventral/intermediate layers) and a cotton pad/nail bed, were several orders of magnitude greater than MIC90 and MFC90 for three major dermatophytes. ME1111 concentrations 3 days after a single and 14 days after multiple dosing of 10% formulation were 253 and 7991 µg/g nail, respectively, and superior to those of 8% ciclopirox control. ME1111 concentration (µg equivalent/cm3) in the cotton pad following 10% ME1111 multiple applications increased linearly throughout the 336 h experiment and was significantly greater than that of 8% ciclopirox. Flux rate of ME1111 averaged as 50.9 µg/cm3/day, which was ca. two orders of magnitude greater than the MIC90 values. The novel antifungal ME1111 penetrated well into human nail plate and its concentrations in the deeper nail and cotton pad after application of 10% formulation were significantly greater than those of ciclopirox.

The Influence of Two Different Foam Creams on Skin Barrier Repair of Foot Xerosis: A Prospective, Double-Blind, Randomised, Placebo-Controlled Intra-Individual Study.

BACKGROUND/AIMS: Dry skin, or xerosis, is a common condition and a key feature of skin diseases like atopic dermatitis (AD) and ichthyosis vulgaris. Foot xerosis may exist without underlying disease and could be related to very mild forms of AD or ichthyosis vulgaris. The synthesis of important skin lipids (cholesterol, free fatty acids and ceramides) is reduced in xerosis and AD, and reduced lipid synthesis is responsible for a lack of lipids and enzymes in the skin barrier. This slows down reorganisation of the lipid lamellae in the stratum corneum (SC). METHODS: Skin barrier integrity was measured by morphometric analysis of the lipid lamellae in the SC after 4 weeks of treatment with a foam cream (active agent vs. placebo). RESULTS: Significant treatment effects were shown after 2 and 4 weeks by an increasing amount of intercellular lipids in the SC. CONCLUSION: This study shows that a quick reorganisation of the SC lipids initiates a good restoration of the whole skin barrier after 4 weeks of treatment with a foam cream.

To Control Site-Specific Skin Gene Expression, Autocrine Mimics Paracrine Canonical Wnt Signaling and Is Activated Ectopically in Skin Disease.

Despite similar components, the heterogeneity of skin characteristics across the human body is enormous. It is classically believed that site-specific fibroblasts in the dermis control postnatal skin identity by modulating the behavior of the surface-overlying keratinocytes in the epidermis. To begin testing this hypothesis, we characterized the gene expression differences between volar (ventral; palmoplantar) and nonvolar (dorsal) human skin. We show that KERATIN 9 (KRT9) is the most uniquely enriched transcript in volar skin, consistent with its etiology in genetic diseases of the palms and soles. In addition, ectopic KRT9 expression is selectively activated by volar fibroblasts. However, KRT9 expression occurs in the absence of all fibroblasts, although not to the maximal levels induced by fibroblasts. Through gain-of-function and loss-of-function experiments, we demonstrate that the mechanism is through overlapping paracrine or autocrine canonical WNT-ß-catenin signaling in each respective context. Finally, as an in vivo example of ectopic expression of KRT9 independent of volar fibroblasts, we demonstrate that in the human skin disease lichen simplex chronicus, WNT5a and KRT9 are robustly activated outside of volar sites. These results highlight the complexities of site-specific gene expression and its disruption in skin disease.

Human nail plate modifications induced by onychomycosis: implications for topical therapy.

PURPOSE: Through the characterisation of the human onchomycotic nail plate this study aimed to inform the design of new topical ungual formulations. METHODS: The mechanical properties of the human nail were characterised using a Lloyd tensile strength tester. The nail's density was determined via pycnometry and the nail's ultrastructure by electron microscopy. Raman spectroscopy analysed the keratin disulphide bonds within the nail and its permeability properties were assessed by quantifying water and rhodamine uptake. RESULTS: Chronic in vivo nail plate infection increased human nailplate thickness (healthy 0.49 ± 0.15 mm; diseased 1.20 ± 0.67 mm), but reduced its tensile strength (healthy 63.7 ± 13.4 MPa; diseased 41.7 ± 5.0 MPa) and density (healthy 1.34 ± 0.01 g/cm(3); diseased 1.29 ± 0.00 g/cm(3)). Onchomycosis caused cell-cell separation, without disrupting the nail disulfide bonds or desmosomes. The diseased and healthy nails showed equivalent water uptake profiles, but the rhodamine penetration was 4-fold higher in the diseased nails using a PBS vehicle and 3 -fold higher in an ethanol/PBS vehicle. CONCLUSIONS: Onchomycotic nails presented a thicker but more porous barrier, and its eroded intracellular matrix rendered the tissue more permeable to topically applied chemicals when an aqueous vehicle was used.

Circumscribed palmar or plantar hypokeratosis: first report on a nonacral site with unique histologic features.

Circumscribed palmar or plantar hypokeratosis was first described by Pérez et al in 2002 as a unique entity of the skin in which they reported 10 patients who presented with well-circumscribed areas of erythematous depressed or eroded skin mostly over the thenar or hypothenar eminences of the palms and less commonly on the soles. Histologically, the lesions demonstrated an abrupt drop-off in the cornified layer resulting in a broad area of hypokeratosis. Pérez et al hypothesized that these lesions were a distinctive epidermal malformation. There have been several reports since, some of which implicate trauma as an etiologic agent; however, the exact etiology remains unclear. The authors present the first case of circumscribed palmar or plantar hypokeratosis on a nonacral site (chest of a 63-year-old man) with novel histological features, including granular parakeratosis and evidence of trauma (subepidermal fibrin and ulcerations).

The influence of a humectant-rich mixture on normalz skin barrier function and on once- and twice-daily treatment of foot xerosis. A prospective, randomized, evaluator-blind, bilateral and untreated-control study.

BACKGROUND: Moisturizers are often used to overcome dry skin conditions. However, cosmetic moisturizers may lack in efficiency and may also deteriorate skin barrier function. The objective of this study was to generate data on a new humectant-rich formulation (15% alfahydroxy acids and 15% urea) in the treatment of normal skin as well as in dry feet with hyperkeratosis and cracked skin with fissures. Changes in permeability and effectiveness of the product after once- and twice-daily applications to the feet will be monitored. METHODS: The study was randomized, bilateral, controlled and evaluator-blind. The first part of the study included 12 healthy volunteers and the second part 50 patients with hyperkeratotic feet. The changes in the skin was evaluated by an expert, the patients and using non-invasive biophysical measurements of skin barrier function (transepidermal water loss, TEWL), erythema, thickness (ultrasound) and hydration (conductance). RESULTS: The humectant-rich formulation increased skin hydration, removed scales and reduced thickness of hyperkeratotic skin. Skin barrier function was improved in normal skin, but no changes in TEWL were noted in the feet. No difference between once and twice-daily applications was found. Some smarting and stinging was noted. CONCLUSION: The humectant-rich formulation efficiently relieved the xerosis on the feet without inducing any weakening of the skin barrier function. Instead the normal skin became more resistant to external insults by the treatment.

The diagnostic value of fungal fluorescence in onychomycosis.

BACKGROUND: Fluorescence of pathogenic fungi has been previously shown when hematoxylin and eosin-stained sections are examined under a fluorescent microscope. We hypothesize that this phenomenon could aid in the evaluation of nail specimens for onychomycosis. METHODS: Forty-eight routinely stained nail sections of periodic acid-Schiff (PAS)-positive onychomycosis, along with 23 PAS-negative control specimens with a clinical diagnosis of onychomycosis, were studied under a fluorescent microscope to determine the clinical usefulness of this technique. RESULTS: In most cases, fluorescence of fungal organisms was noted. Fungi were identified by their tubular or annular shapes with fluorescence surrounding them. The sensitivity and specificity of the method were 96 and 90%, respectively. In some cases, it was difficult to identify the fungi because of the relative paucity of organisms, weak fluorescence and high background fluorescence of eosinophilic nail keratin. CONCLUSIONS: We conclude that fluorescence microscopy can be used as a rapid screening tool for identification of fungi in nail specimens.

Callus formation is associated with hyperproliferation and incomplete differentiation of keratinocytes, and increased expression of adhesion molecules.

BACKGROUND: A callus is a local thickening of skin, characterized by accelerated keratinization and a reduced rate of desquamation. However, the mechanism of callus formation is not fully understood. OBJECTIVES: To evaluate the expression patterns, in callused skin, of genes that are implicated in keratinization and adhesion/desquamation. METHODS: Samples of skin from the dorsum of the foot (DF), centre of the plantar arch (CP) and anterior aspect of the heel (AH) were obtained from fresh cadavers, and protein and gene expression were determined by immunohistochemistry and reverse transcription-polymerase chain reaction, respectively. RESULTS: The stratum corneum in the DF showed a splitting phenotype by conventional haematoxylin and eosin staining, while the stratum corneum was normal in the AH. Cells of the stratum corneum in the AH were nonsquamous. Expression of cornification-related molecules including involucrin, filaggrin, caspase 14 and calcium-sensing receptor was higher in the AH. Similarly, expression of adhesive proteins such as corneodesmosin, desmoglein 1 and desmocollin 1 was increased in the AH. However, protease-activated receptor 2 expression was reduced in the stratum granulosum in the AH. The number of proliferating cells in the stratum basale was significantly increased in the AH, compared with the DF and CP. CONCLUSIONS: Our data suggest that calluses form as a result of hyperproliferation and incomplete differentiation of epidermal keratinocytes, and increased expression of adhesion molecules.

Evaluation of zinc level in skin of patients with necrolytic acral erythema.

BACKGROUND: Necrolytic acral erythema (NAE) is considered a cutaneous sign of hepatitis C virus infection. Its exact pathogenesis is still not fully understood, with some reports about decreased serum zinc levels but none about its level in the skin. OBJECTIVES: To assess skin (lesional and perilesional) and serum zinc levels in patients with NAE and compare them with levels in control subjects. METHODS: Fifteen patients with NAE and 10 healthy controls were included in this study. Assessment of zinc level, in serum by graphite furnace atomic absorption spectrophotometry and in lesional and perilesional skin biopsies by flame atomic absorption spectrometry, was done in all subjects. Re-evaluation of serum and lesional skin zinc level was done after oral zinc treatment. RESULTS: Mean±SD zinc levels were significantly lower in patients (serum 0·44 ± 0·13 mg L(-1) ; lesional skin 42·6 ± 18·9 mg L(-1) ; perilesional skin 32·5 ± 17·2 mg L(-1) ) than controls (serum 1·17 ± 0·29 mg L(-1) ; skin 100·1 ± 2·77 mg L(-1) ), with a positive correlation between lesional and perilesional skin zinc (r = 0·91, P < 0·01). Oral zinc supplementation significantly increased serum and skin zinc levels (by 159% and 4%, respectively; P < 0·05). CONCLUSIONS: NAE is associated with decreased serum and skin zinc levels. Oral zinc supplementation corrects decreased levels of plasma and skin zinc much earlier than the desired clinical benefits appear.

Novel findings of Langerhans cells and interleukin-17 expression in relation to the acrosyringium and pustule in palmoplantar pustulosis.

BACKGROUND: Palmoplantar pustulosis (PPP) is a chronic and intensely inflammatory skin disease with pustules, erythema and scaling localized to the palms and soles. To date, no specific treatment is known. Earlier findings indicate the acrosyringium as the target for the inflammation. OBJECTIVES: To identify specific features of the PPP inflammatory cell infiltrate and mediators of inflammation, which might provide insight into the pathogenesis and possible future treatment of the disease. METHODS: Skin biopsies were taken from 23 patients with typical PPP (23 from involved skin and seven from noninvolved skin) and from 18 healthy controls (10 nonsmokers, eight smokers). Cell infiltrates and inflammation mediators were studied with immunohistochemistry. RESULTS: A strong inflammation was observed in lesional skin of PPP. Our main findings of Langerhans cells and interleukin-17 close to or in the acrosyringium differs from findings in psoriasis vulgaris. Other inflammatory cells such as CD4+, CD8+, regulatory T cells and CD11a+ cells were also accumulated close to the sweat duct in epidermis and papillary dermis. More CD4+, CD8+, Langerhans cells, plasmacytoid dendritic cells and a higher proportion of regulatory T cells/CD3+ cells were seen in noninvolved palmar skin from patients with PPP compared with healthy controls. CONCLUSIONS: Our novel findings indicate that the inflammation in PPP is initiated by the 'stand-by' innate immune system at the acrosyringium.

Studies in drug transport vs. current in iontophoretic onychomycosis treatment.

An iontophoretic treatment system for onychomycosis, using drug applicators targeting either toe nail only or nail and surrounding tissue, is analyzed. Phase 1 clinical data shows levels of drug delivery that differ unexpectedly from relative dosing level to multiple tissue types. Current monitoring and analysis techniques, coupled with assays of drug delivery into excised nail and cadaver toe, were used to evaluate drug delivery vs. current flow. The results indicate good correlation with piecewise linear models of current flow and extracted drug in the nail-only application. For the nail and surrounding tissue application, assayed drug levels indicate that on average, drug load per unit dose (mA-min) is more efficient into nail than into surrounding tissue (2.38:1 ug/mA-min nail vs. surrounding tissue, n=6, p=0.009).

Elephantiasis nostras verrucosa or "mossy foot lesions" in lymphedema praecox: report of a case.

Elephantiasis nostras verrucosa is a rare disorder that results from chronic obstructive lymphedema. It is characterized clinically by deforming, nonpitting edema; malodorous hyperkeratosis with generalized lichenification; cobblestoned papules; and verrucous changes, that often result in extreme enlargement of the involved body part. Although elephantiasis nostras verrucosa is striking in clinical appearance, biopsy reveals only moderately abnormal findings: pseudoepitheliomatous hyperplasia with dilated lymphatic spaces in the dermis, accompanied by chronic inflammation and fibroblast proliferation. The term elephantiasis nostras (nostras means "from our region") has traditionally been used to differentiate temperate zone disease from the classic disease process, elephantiasis tropica, which is defined by chronic filarial lymphatic obstruction caused by Wuchereria bancrofti, Wuchereria malayi, or Wuchereria pacifica. We present a case report of elephantiasis nostras verrucosa arising as a result of lymphedema praecox.

Recent progress on the topical therapy of onychomycosis.

Onychomycosis is a fungal infection of the fingernails and toenails that results in thickening, discoloration, splitting of the nails and lifting of the nail from the nail bed. The disease is caused by dermatophytes and has a high incidence within the general population, especially among older individuals. Present treatment options include both oral and topical drugs, with oral therapies giving better outcomes; however, neither of these treatment options provides high cure rates that are durable. The difficulty in treating onychomycosis results from the deep-seated nature of the infection within the nail unit (nail plate, nail bed and surrounding tissue) and the inability of drugs to effectively reach all sites. Ongoing drug development activities have focused on novel delivery technologies to facilitate penetration of existing antifungal drugs through the nail plate and on the discovery of inherently penetrable antifungals. AN-2690 represents an oxaborole antifungal that is designed to penetrate the nail plate and is showing promising results in clinical trials.

Excess dietary cystine intensifies the adverse effect of a methionine deficiency in the cat.

Foot pad dermatitis has been observed in turkeys, puppies and kittens fed diets deficient in methionine. Excess cystine aggravated the lesions and decreased body weight gain in puppies and turkeys. The objective of this study was to determine whether methionine deficiency induced perioral and foot pad lesions in kittens and whether excess cystine exacerbated the lesions. Eighteen kittens were divided into three groups and offered one of three diets: diet 1, low-methionine, low-cystine (LMLC; 1.6 g methionine and 1.6 g cystine/kg diet); diet 2, low-methionine, high-cystine (HMHC; 1.6 methionine and 15 g cystine/kg diet); diet 3, high-methionine, high-cystine (HMHC; 15 g methionine and 15 g cystine/kg diet). Kittens in the LMLC group lost body weight, whereas those in the LMHC group maintained their body weight and those in the HMHC group gained weight. Plasma methionine concentrations were significantly higher (p < 0.001) for the HMHC group than for the LMLC and LMHC groups. Plasma cyst(e)ine (sum of cysteine and cystine) concentrations were different (p < 0.001) among all the three groups. Two kittens given the LMLC diet developed mild perioral lesions. All kittens receiving the LMHC diet developed foot pad lesions and severe perioral lesions. Histopathological changes observed in perioral biopsy specimens were similar to those described in protein deficiency. In conclusion, the results showed that a diet severely deficient in methionine causes perioral lesions in kittens, and that addition of excess cystine to the diet aggravates the perioral lesions and also causes foot pad lesions.

Up-regulation of cytokeratin expression in canine distemper virus-infected canine footpad epidermis.

Cytokeratin expression was assessed in footpad epidermis from dogs using immunohistochemistry. Four groups of dogs were studied: dogs with experimentally induced distemper and with canine distemper virus (CDV) in footpad epidermis (group 1, n = 7); dogs with experimentally induced distemper and without CDV in footpad epidermis (group 2, n = 4); inoculated dogs without distemper and without CDV in the footpad epidermis (group 3, n = 8), and noninoculated dogs without distemper (group 4, n = 2). No increase in thickness of the footpad epidermis was present in any of these groups. Sections of metacarpal or metatarsal pads were stained for cytokeratin (CK)14 (proliferation-associated), CK10 (correlated with early differentiation), and for involucrin (associated with terminal differentiation). CK14 was present in basal keratinocytes of all groups, but staining intensity decreased towards the corneal layer in groups 2-4, but not in group 1. CK10 was present in the spinous and granular layer of all groups, but staining of the granular layer was much stronger in group 1. Involucrin was present in the granular layer of footpads of group 1 and only in the upper part of this layer in groups 2-4. The results demonstrate increased staining intensity and/or wider distribution within the footpad epidermis in group 1 dogs when compared to the other groups. This was interpreted as up-regulation in expression of these proteins. These findings suggest that presence of CDV antigen and mRNA in footpad epidermis was associated with an increase in expression of CK14, CK10 and involucrin. The potential role of this up-regulation in cytokeratin expression in the development of CDV-induced digital hyperkeratosis remains speculative at the moment and requires further studies.

Volar melanotic macules in a Japanese man with histopathological postinflammatory pigmentation: the volar counterpart of mucosal melanotic macules.

BACKGROUND: Volar melanotic macules are asymptomatic light-brown or tannish-grey macules usually found on the palms and/or soles of blacks, although they have also been reported on the volar surfaces of whites. Similar lesions have not been reported before in Japanese people. Since the cause is as yet unknown, it remains to be discussed whether they are a distinct entity. METHODS: In this report, a 52-year-old Japanese man with volar melanotic macules is reported with the clinical and histopathological findings. RESULTS: A 52-year-old Japanese man presented with many light-brown macules on his bilateral soles. He had a 20-year history of tinea pedis. Histopathological examination revealed melanophages and inflammatory infiltrates in the superficial dermis. There was a slight increase in melanin granules around the acrosyringium. Fontana-Masson stain revealed a slight increase in melanin granules in the basal layer including the acrosyringium and superficial dermis. These changes corresponded with postinflammatory pigmentation. CONCLUSIONS: This is the first report of volar melanotic macules in Japanese people. We suggest that volar melanotic macules is not an independent entity but a clinicopathological one that includes postinflammatory pigmentation, and that the condition is the volar counterpart of mucosal melanotic macules.

Guess what! Porokeratosis of Mibelli.

A 72-year-old man had noticed, in his early forties, the appearance of well-defined papulous hyperkeratotic lesions, with increasing growth, located on both sides of his feet. After twenty-five years he consulted a dermatologist for the first time. Physical examination showed annular papules and rose-coloured plaques with atrophic centres, some of them hypopigmented, with higher and irregular borders, separated from the surrounding skin by longitudinal and well-defined furrows. The lesions presented variable sizes and shapes, some of them punctate, involving exclusively and in a bilateral form, both sides, back and sole of the feet (Figs. 1 and 2). The patient did not report any subjective symptoms. He was immunocompetent and did not remember that any relative had the same disease, nor had he been subjected to radiation treatment.

Immunohistochemical observation of cytokeratins in keratinous cysts including plantar epidermoid cyst.

Sixteen cases of epidermal cyst (EC) (6 cases of conventional EC and 10 cases of plantar epidermoid cyst (PEC)) and 9 cases of trichilemmal cyst (TC) were examined by an immunohistochemical technique using various antibodies against cytokeratins and human papilloma virus (HPV) in order to clarify their histogenesis. There was no difference in immunoreactivities between EC and PEC with or without HPV infection. In TC, the inner layers of the cyst wall were stained with the antibody E3 (CK17), and the outermost layer was stained with the antibodies 4.1.18 (CK8) and 170.2.14 (CK19). In PEC and EC, however, the cyst wall didn't react with these antibodies, and differentiation-specific cytokeratins were expressed in the inner layer. These results confirmed that the immunoreactivities of PEC and EC were identical to those of normal epidermis or infundibulum, and that those of TC were similar to the outer root sheath between the lower infundibulum and isthmus. Although PEC has been recently reported to originate from eccrine ducts, there was a significant difference in immunoreactivities between PEC and eccrine ducts. Furthermore, on the basis of the fact that sole skin has no hair follicles, PEC was speculated to originate from epidermal implantation.

Pharmacokinetics of three doses of once-weekly fluconazole (150, 300, and 450 mg) in distal subungual onychomycosis of the toenail.

BACKGROUND: Preliminary clinical data suggest that fluconazole is effective in the treatment of patients with onychomycosis. To design optimum dosage regimens, a better understanding of fluconazole's distribution into and elimination from nails is needed. OBJECTIVE: The purpose of this study was to determine plasma and toenail concentrations of fluconazole. METHODS: In this multicenter, randomized, double-blind investigation, fluconazole (150 mg, 300 mg, or 450 mg) or matching placebo was administered once a week for a maximum of 12 months to patients with onychomycosis of the toenail. A total of 151 subjects participated in the pharmacokinetic assessment. Blood samples and distal toenail clippings from both affected and healthy nails were obtained for fluconazole concentration determinations at baseline, at the 2-week visit, at each monthly visit until the end of treatment, and then at 2, 4, and 6 months (nail samples only at the latter two) after fluconazole was discontinued. RESULTS: Fluconazole was detected in healthy and affected nails at the 2-week assessment in nearly all subjects. The median time to reach steady-state fluconazole concentrations in healthy nails was 4 to 5 months in the three fluconazole dose groups. In affected nails, steady-state fluconazole concentrations were achieved more slowly, with a median time of 6 to 7 months. At the 8-month assessment, affected toenail fluconazole concentrations were higher than corresponding plasma fluconazole concentrations, with ratios of 1.31 to 1.50 in the three active treatment groups. Toenail concentrations of fluconazole declined slowly after treatment was discontinued, with elimination half-lives of 2.5, 2.4, and 3.7 months for the 150, 300, and 450 mg doses, respectively. Measurable fluconazole concentrations were still present in toenails at 6 months after treatment in most subjects. CONCLUSION: Fluconazole penetrates healthy and diseased nails rapidly, yielding detectable concentrations after two weekly doses. Once it penetrates nail, fluconazole persists for up to 6 months or longer after therapy is stopped. These favorable pharmacokinetic characteristics support a once-weekly fluconazole dosage regimen for the treatment of patients with onychomycosis.