A Detailed Analysis of Infarct Patterns and Volumes at 24-hour Noncontrast CT and Diffusion-weighted MRI in Acute Ischemic Stroke Due to Large Vessel Occlusion: Results from the ESCAPE-NA1 Trial.

Background The effect of infarct pattern on functional outcome in acute ischemic stroke is incompletely understood. Purpose To investigate the association of qualitative and quantitative infarct variables at 24-hour follow-up noncontrast CT and diffusion-weighted MRI with 90-day clinical outcome. Materials and Methods The Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke, or ESCAPE-NA1, randomized controlled trial enrolled patients with large-vessel-occlusion stroke undergoing mechanical thrombectomy from March 1, 2017, to August 12, 2019. In this post hoc analysis of the trial, qualitative infarct variables (predominantly gray [vs gray and white] matter involvement, corticospinal tract involvement, infarct structure [scattered vs territorial]) and total infarct volume were assessed at 24-hour follow-up noncontrast CT or diffusion-weighted MRI. White and gray matter infarct volumes were assessed in patients by using follow-up diffusion-weighted MRI. Infarct variables were compared between patients with and those without good outcome, defined as a modified Rankin Scale score of 0-2 at 90 days. The association of infarct variables with good outcome was determined with use of multivariable logistic regression. Separate regression models were used to report effect size estimates with adjustment for total infarct volume. Results Qualitative infarct variables were assessed in 1026 patients (mean age ± standard deviation, 69 years ± 13; 522 men) and quantitative infarct variables were assessed in a subgroup of 358 of 1026 patients (mean age, 67 years ± 13; 190 women). Patients with gray and white matter involvement (odds ratio [OR] after multivariable adjustment, 0.19; 95% CI: 0.14, 0.25; P < .001), corticospinal tract involvement (OR after multivariable adjustment, 0.06; 95% CI: 0.04, 0.10; P < .001), and territorial infarcts (OR after multivariable adjustment, 0.22; 95% CI: 0.14, 0.32; P < .001) were less likely to achieve good outcome, independent of total infarct volume. Conclusion Infarct confinement to the gray matter, corticospinal tract sparing, and scattered infarct structure at 24-hour noncontrast CT and diffusion-weighted MRI were highly predictive of good 90-day clinical outcome, independent of total infarct volume. Clinical trial registration no. NCT02930018 © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Mossa-Basha in this issue.

Treatment of postscabies prurigo with diflucortolone and chlorquinaldol in a group of African refugees.

Postscabies prurigo (PSP) is caused by a delayed hypersensitivity reaction to antigens of the mite. Treatment is based on potent topical or intralesional corticosteroids. We present the results of a study on the effectiveness of a topical combination of diflucortolone and chlorquinaldol. Eighteen African patients who had been previously affected by scabies and treated with permethrin were enrolled. The diagnosis of PSP was made by excluding other causes through microscopic examinations. All patients were treated with the drug combination by two applications daily for two weeks. The primary study objective was to evaluate the itch by a visual analogue scale (VAS) of 0-100. Fifteen patients (83.3%) could be evaluated. All reported improvements: from 86/100 at the start to 29/100 (-57/100) at the end of treatment. Chlorquinaldol, known as an antiseptic agent, demonstrated, according to results of this study, an important anti-itch action.

The association of isoconazole-diflucortolone in the treatment of pediatric tinea corporis.

BACKGROUND: Tinea corporis is a common mycotic infection in children. Staphylococcus aureus superinfections may be observed in atopic children with tinea corporis suffering from severe pruritus and consequent scratching. OBJECTIVE: From 2006 to 2011, we observed 288 children with mycologically proven tinea corporis. In 39 of them (13.5%) tinea corporis was superinfected by S. aureus: all these children were affected by atopic dermatitis. We interpreted these bacterial superinfections as the clinical result of scratching due to pruritus. METHODS: In 2012, we decided to treat all children with a single lesion of tinea corporis with a combination of 1% isoconazole nitrate and 0.1% diflucortolone valerate cream (one application/day for 5-7 days), followed by a treatment with isoconazole or clotrimazole or ciclopirox cream (two applications/day for two weeks). RESULTS: From 2012 to 2014, we observed 108 children with tinea corporis confirmed by mycological examinations. Clinical and mycological recovery was observed in 93 of them (86.1%). Only four of these children (3.7%) developed S. aureus superinfections. CONCLUSIONS: Our study in atopic children with tinea corporis superinfected by S. aureus confirms that a topical therapy with the association isoconazole-diflucortolone is useful and safe.

Nanostructured lipid carriers as semisolid topical delivery formulations for diflucortolone valerate.

CONTEXT: Topical treatment of skin disease needs to be strategic to ensure high drug concentration in the skin with minimum systemic absorption. OBJECTIVE: The aim of this study was to produce semisolid nanostructured lipid carrier (NLC) formulations, for topical delivery of the corticosteroid drug, diflucortolone valerate (DFV), with minimum systemic absorption. METHOD: NLC formulations were developed using a high shear homogenization combined with sonication, using Precirol® ATO5 or Tristearin® as the solid lipid, Capryol™ or isopropyl myristate as the liquid lipid and Poloxamer® 407 as surfactant. The present study addresses the influence of different formulations composition as solid lipid, liquid lipid types and concentrations on the physicochemical properties and drug release profile from NLCs. RESULTS AND DISCUSSION: DFV-loaded NLC formulations possessed average particle size ranging from 160.40 nm to 743.7 nm with narrow polydispersity index. The encapsulation efficiency was improved by adding the lipid-based surfactants (Labrasol® and Labrafil® M1944CS) to reach 68%. The drug release from the investigated NLC formulations showed a prolonged release up to 12 h. The dermatopharmacokinetic study revealed an improvement in drug deposition in the skin with the optimized DFV-loaded NLC formulation, in contrast to a commercial formulation. CONCLUSION: NLC provides a promising nanocarrier system that work as reservoir for targeting topical delivery of DFV.

Effective topical delivery systems for corticosteroids: dermatological and histological evaluations.

Atopic dermatitis (AD) is a chronic and relapsing skin disease with severe eczematous lesions. Long-term topical corticosteroid treatment can induce skin atrophy, hypopigmentation and transepidermal water loss (TEWL) increase. A new treatment approach was needed to reduce the risk by dermal targeting. For this purpose, Betamethasone valerate (BMV)/Diflucortolone valerate (DFV)-loaded liposomes (220-350 nm) were prepared and incorporated into chitosan gel to obtain adequate viscosity (∼13 000 cps). Drugs were localized in stratum corneum + epidermis of rat skin in ex-vivo permeation studies. The toxicity was assessed on human fibroblast cells. In point of in-vivo studies, pharmacodynamic responses, treatment efficacy and skin irritation were evaluated and compared with previously prepared nanoparticles. Liposome/nanoparticle in gel formulations produced higher paw edema inhibition in rats with respect to the commercial cream. Similar skin blanching effect with commercial creams was obtained via liposome in gels although they contain 10 times less drug. Dermatological scoring results, prognostic histological parameters and suppression of mast cell numbers showed higher treatment efficiency of liposome/nanoparticle in gel formulations in AD-induced rats. TEWL and erythema measurements confirmed these results. Overview of obtained results showed that liposomes might be an effective and safe carrier for corticosteroids in skin disease treatment.

Isolated benign primary cutaneous plasmacytosis in a child.

Isolated benign primary cutaneous plasmacytosis in a child is a very rare and benign disease. Herein we present a case of this condition occurring in a child who showed good response to topical corticosteroid.

Cutaneous polyarteritis nodosa successfully treated with topical diflucortolone valerate: a case report & review of the literature.

Cutaneous Polyarteritis Nodosa (cPAN) was first described in 1931. cPAN is considered a rare disease, its true incidence is unknown. The age of onset is diverse. Most studies have shown no significant gender predominance. cPAN presents with distinct skin findings, such as a maculopapular rash, subcutaneous nodules, livedoid vasculitis, panniculitis, ischemic finger lesions, or erythematous patchy rash. Etiology is unclear. It is still believed to be an immune complex-mediated disease, although a possible mechanism recently proposed relates a familial form of the disease to impaired activity of Adenosine Deaminase 2. cPAN may reflect an underlying disease, infection or medical treatment. There is no consensus as to initial treatment, dosage and length of treatment. Patients with constitutional symptoms, visceral involvement, a more severe course of the disease, or high acute phase reactants, were treated mainly with systemic corticosteroids and/or cytotoxic agents for varying durations. However, persistence of cutaneous lesions has been documented. We describe a 14 year old male suffering from persistent cPAN, with no constitutional symptoms or involvement of internal organs. The patient was treated with a local corticosteroid-based ointment during exacerbations, until complete remission. Although reported in only one study, treatment with topical corticosteroid compound may result in significant improvement or complete regression of skin lesions in cPAN patients.

Isoconazole nitrate: a unique broad-spectrum antimicrobial azole effective in the treatment of dermatomycoses, both as monotherapy and in combination with corticosteroids.

Fungal skin infections, or dermatomycoses, are associated with a broad range of pathogens. Involvement of gram-positive bacteria is often suspected in dermatomycoses. Inflammation plays an important role in dermatomycoses, displaying a close association between frequent inflammation and reduced skin-related quality of life. Isoconazole nitrate (ISN) is a broad-spectrum antimicrobial agent with a highly effective antimycotic and gram-positive antibacterial activity, a rapid rate of absorption and low systemic exposure potential. ISN is effective against pathogens involved in dermatomycoses, with minimum inhibitory concentrations well below the concentration of ISN in skin and hair follicles. The combination of the corticosteroid diflucortolone valerate with ISN (Travocort) increases the local bioavailability of ISN. Compared with ISN monotherapy, Travocort has a faster onset of antimycotic action, faster relief of itch and other inflammatory symptoms, improved overall therapeutic benefits and earlier mycological cure rate. Travocort is effective in the treatment of inflammatory mycotic infections, and also in the eradication of accompanied gram-positive bacterial infections. The rapid improvement observed with Travocort treatment, combined with favourable safety and tolerability, results in higher patient satisfaction, and therefore, can be an effective tool to increase treatment adherence in patients with dermatomycoses accompanied by inflammatory signs and symptoms.

Inflammatory tinea pedis with bacterial superinfection effectively treated with isoconazole nitrate and diflucortolone valerate combination therapy.

Undetected tinea pedis in a patient with diabetes can lead to serious bacterial infections with potentially serious consequences, such as foot amputations. Here we report on a 60-year-old patient with diabetes presenting with pain, severe pruritus, and malodour in the foot's interdigital area, and subsequently, diagnosed with inflammatory tinea pedis with bacterial superinfection. The patient was successfully treated with Travocort cream containing isoconazole nitrate 1% and diflucortolone valerate 0.1%; marked improvement occurred within 5 days.

Misdiagnosed zoophile tinea faciei and tinea corporis effectively treated with isoconazole nitrate and diflucortolone valerate combination therapy.

There have been few published reports on the human transmission of Trichophyton mentagrophytes, a zoophilic fungus frequently occurring in pets. Here we report on 2 girls, living with a pet dwarf rabbit, who presented with inflammatory skin lesions positive for T. mentagrophytes and subsequently diagnosed as zoophile tinea faciei and tinea corporis. The patients were successfully treated with systemic terbinafine and 2-week therapy with Travocort cream containing isoconazole nitrate 1% and diflucortolone valerate 0.1%.

Effective treatment of tinea corporis due to Trichophyton mentagrophytes with combined isoconazole nitrate and diflucortolone valerate therapy.

Trichophyton mentagrophytes is the dermatophyte species most commonly reported in cases of guinea pig-associated dermatophytosis (or guinea pig fungus) a condition that more often affects children than adults. In this case, a 13-year-old girl with recent direct contact with guinea pigs presented with a previously undertreated inflammatory skin lesion on the left side of her upper body, which was positive both for Trichophyton mentagrophytes and Staphylococcus epidermidis. The condition was subsequently diagnosed as tinea corporis due to Trichophyton mentagrophytes with concomitant bacterial infection and effectively treated with 2 weeks of twice-daily application of Travocort cream containing isoconazole nitrate 1% and diflucortolone valerate 0.1%. Visible improvement in the lesion was apparent after only 1 week of treatment.

Trichophyton mentagrophytes cause underestimated contagious zoophilic fungal infection.

Trichophytia infection, paraphrased cuddly toy mycosis, occurs primarily in prepubertal children, occasionally in infants and adults. The presented case shows the highly contagious infection of four family members with Trichophyton mentagrophytes. Effective treatment requires detailed diagnostic: identifying the dermatophyte, finding the infection source, treating the infection carriers. Tinea must be treated systemically and topically because of infectivity and ignitability. Systemic terbinafine or fluconazole treatment and topical fixed combination isoconazole nitrate/diflucortolone valerate are recommended.

Effective treatment of erythrasma-associated inflammation and pruritus with isoconazole nitrate and diflucortolone valerate combination therapy.

A warm and moist environment is a common risk factor for erythrasma, a condition characterized by pruritic, scaly and erythematous tan patches on the skin. Here we report on a 13-year-old athletic student presenting with pruritus and mild burning on her left medial thigh, and subsequently diagnosed with erythrasma. The patient was successfully treated with a 5-day regimen of Travocort cream containing isoconazole nitrate 1% and diflucortolone valerate 0.1%.

Rapid relief of intertrigo-associated pruritus due to Candida albicans with isoconazole nitrate and diflucortolone valerate combination therapy.

A 43-year-old male, with intertrigo due to Candida albicans located at the inguinal folds and accompanied by severe pruritus, was treated with topical 1% isoconazole nitrate and 0.1% diflucortolone valerate (2 applications/day for 7 days). An improvement of pruritus was reported 2 days after the beginning of the treatment. Skin lesions improved after 3 days of treatment. Complete remission of both skin lesions and pruritus was observed at day 7. No side effects were observed.

Enhanced dermal delivery of diflucortolone valerate using lecithin/chitosan nanoparticles: in-vitro and in-vivo evaluations.

The objective of this study was to prepare a suitable formulation for dermal delivery of diflucortolone valerate (DFV) that would maintain the localization in skin layers without any penetration and to optimize efficiency of DFV. Drug-loaded lecithin/chitosan nanoparticles with high entrapment efficiency (86.8%), were successfully prepared by ionic interaction technique. Sustained release of DFV was achieved without any initial burst release. Nanoparticles were also incorporated into chitosan gel at different ratios for preparing a more suitable formulation for topical drug delivery with adequate viscosity. In ex-vivo permeation studies, nanoparticles increased the accumulation of DFV especially in the stratum corneum + epidermis of rat skin without any significant permeation. Retention of DFV from nanoparticle in chitosan gel formulation (0.01%) was twofold higher than commercial cream, although it contained ten times less DFV. Nanoparticles in gel formulations produced significantly higher edema inhibition in rats compared with commercial cream in in-vivo studies. Skin blanching assay using a chromameter showed vasoconstriction similar to that of the commercial product. There were no barrier function changes upon application of nanoparticles. In-vitro and in-vivo results demonstrated that lecithin/chitosan nanoparticles in chitosan gel may be a promising carrier for dermal delivery of DFV in various skin disorders.

Isoconazole nitrate vs isoconazole nitrate and diflucortolone valerate in the treatment of tinea inguinalis: results of a multicenter retrospective study.

BACKGROUND AND OBJECTIVE: Many tinea inguinalis infections are characterized by pronounced inflammatory lesions and pruritus. Therefore, a therapy with a topical corticosteroid in addition to a topical antimycotic agent might be beneficial. In this multicenter, retrospective study, we compared the mycological and clinical efficacy and tolerability of isoconazole nitrate alone vs isoconazole nitrate and diflucortolone valerate in 58 adult patients with tinea inguinalis. PATIENTS AND METHODS: Treatment duration was three weeks. The efficacy of the treatment was based on the assessment of several signs and symptoms, which were collected on a 4-point scale. All patients were examined clinically before the beginning of the treatment, one week later, two weeks later, and at the end of the treatment. Mycological examinations were performed before the beginning of the treatment and at the end of the study. RESULTS: Treatment results with the combination of isoconazole nitrate and diflucortolone valerate were superior regarding erythema and pruritus. Both erythema and pruritus resolved in a larger percentage of patients and more quickly. Both regimens were well tolerated. Mycological cure rates were similar in both groups of patients. CONCLUSIONS: Combination therapy with isoconazole nitrate and diflucortolone valerate is an effective and well-tolerated regimen in adult patients with tinea inguinalis.