The lipid profile of three Malassezia species assessed by Raman spectroscopy and discriminant analysis

Malassezia yeasts constitute the major eukaryotic cutaneous flora of homoeothermic vertebrates. These lipophilic yeasts are able to cause, trigger, or aggravate common skin diseases under favorable conditions. Species identification and subspecies differentiation is currently based on morphological characteristics, lipid assimilation profile, and molecular tests. Mass spectrometry has been also reported as a reliable, yet costly and labor-intensive, method to classify Malassezia yeasts. Here, we introduce Raman spectroscopy as a new molecular technique able to differentiate three phylogenetically close Malassezia species (M.globosa, M.pachydermatis, and M.sympodialis) by examining their lipid metabolic profile. Using Raman spectroscopy, lipid fingerprints of Malassezia cultures on Leeming-Notman agar, were analyzed by spectral bands assignment and partial least squares discriminant analysis. Our results demonstrate differential utilization of lipid supplements among these three species and the ability of Raman spectroscopy to rapidly and accurately discriminate them by predictive modelling.

Alterations in the inflammatory cells infiltrating basal cell carcinomas during immunocryosurgery

Immunocryosurgery, the combination modality of a cryosurgery session at day 14 of a 5-week daily imiquimod treatment cycle, has shown remarkable efficacy in the treatment of basal cell carcinoma (BCC). The modality was designed to exploit synergy of antitumor effects, including the induction of immune responses, elicited by imiquimod and cryosurgery. Herein, we report on the infiltration of the BCC by selected inflammatory cell species during an immunocryosurgery treatment cycle. The density of tissue infiltrating CD68⁺, CD3⁺ and Foxp3⁺ cells was studied by immunohistochemistry in 56 BCC biopsies from 28 treated sites (26 patients) at baseline and at days 12, 16 or 28 during treatment. Immunocryosurgery induces statistically significant alterations in all three cell species (p < 0.003): The density of CD68⁺ increased already by day 12 and remained at a higher level during the treatment thereafter. The density of CD3⁺ cells increased significantly between days 12 and 16 of treatment. The density of T_reg (Foxp3⁺) cells increased in the early phase of treatment (highest at day 12) to decrease significantly already 2 days after the cryosurgery session (day 16) and thereafter up to day 28 of the treatment cycle (p = 0.033). Within the tumor tissue, these alterations result in an abrupt increase in the CD3⁺/Foxp3⁺ ratio, a finding suggesting that the cryosurgical perturbation may probably play a decisive modulating role in the cellular composition of the inflammatory infiltrate during immunocryosurgery, eventually heralding the induction of an effective tumor-destructing immune response.

Late fusion of deep and shallow features to improve discrimination of actinic keratosis from normal skin using clinical photography

BACKGROUND

Actinic keratosis (AK) is a common premalignant skin lesion that can potentially progress to squamous cell carcinoma. Appropriate long-term management of AK requires close patient monitoring in addition to therapeutic interventions. Computer-aided diagnostic systems based on clinical photography might evolve in the future into valuable adjuncts to AK patient management. The present study proposes a late fusion approach of color-texture features (shallow features) and deep features extracted from pre-trained convolutional neural networks (CNN) to boost AK detection accuracy on clinical photographs.

MATERIALS AND METHODS

System uses a sliding rectangular window of 50 × 50 pixels and a classifier that assigns the window region to either the AK or the healthy skin class. 6010 and 13 915 cropped regions of interest (ROI) of 50 × 50 pixels of AK and healthy skin, respectively, from 22 patients were used for system implementation. Different support vector machine (SVM) classifiers employing shallow or deep features and their late fusion using the max rule at decision level were compared with the McNemar test and Yule's Q-statistic.

RESULTS

Support vector machine classifiers based on deep and shallow features exhibited overall competitive performances with complementary improvements in detection accuracy. Late fusion yielded significant improvement (6%) in both sensitivity (87%) and specificity (86%) compared to single classifier performance.

CONCLUSION

The parallel improvement of sensitivity and specificity is encouraging, demonstrating the potential use of our system in evaluating AK burden. The latter might be of value in future clinical studies for the comparison of field-directed treatment interventions.

Psoriasis and inflammatory bowel disease: links and risks

Psoriasis and the spectrum of inflammatory bowel diseases (IBD) are chronic, inflammatory, organotropic conditions. The epidemiologic coexistence of these diseases is corroborated by findings at the level of disease, biogeography, and intrafamilial and intrapatient coincidence. The identification of shared susceptibility loci and DNA polymorphisms has confirmed this correlation at a genetic level. The pathogenesis of both diseases implicates the innate and adaptive segments of the immune system. Increased permeability of the epidermal barrier in skin and intestine underlies the augmented interaction of allergens and pathogens with inflammatory receptors of immune cells. The immune response between psoriasis and IBD is similar and comprises phagocytic, dendritic, and natural killer cell, along with a milieu of cytokines and antimicrobial peptides that stimulate T-cells. The interplay between dendritic cells and Th17 cells appears to be the core dysregulated immune pathway in all these conditions. The distinct similarities in the pathogenesis are also reflected in the wide overlapping of their therapeutic approaches. Small-molecule pharmacologic immunomodulators have been applied, and more recently, biologic treatments that target proinflammatory interleukins have been introduced or are currently being evaluated. However, the fact that some treatments are quite selective for either skin or gut conditions also highlights their crucial pathophysiologic differences. In the present review, a comprehensive comparison of risk factors, pathogenesis links, and therapeutic strategies for psoriasis and IBD is presented. Specific emphasis is placed on the role of the immune cell species and inflammatory mediators participating in the pathogenesis of these diseases.

Immunocryosurgery - an effective combinational modality for Bowen's disease

Bowen's disease (BD) is widely treated with topical imiquimod or cryosurgery. The present single-center retrospective study reports on the application of standardized immunocryosurgery (cryosurgery during ongoing topical imiquimod) for the treatment of BD. Daily imiquimod 5% cream was applied on BD lesion and a 5 mm rim around it in 5-week treatment cycles; cryosurgery (liquid N₂ , open spray; 2 cycles, 15 second each) was performed at the end of the second week of each treatment cycle. Between 1/1/2009 and 31/12/2014 21 patients (mean age ± SD: 74.4 ± 8.0 years; 12 males) with 24 lesions (mean maximum diameter ± SD: 45.8 ± 50.9 mm; range: 9-200 mm) completed the protocol. The anatomic distribution of the lesions included face/scalp (Ν = 14), neck/trunk (Ν = 6), and extremities (Ν = 4). Twenty-one out of twenty-four lesions with diameter <80 mm cleared after one immunocryosurgery cycle, while the rest three tumors (with the largest diameters: 100, 180, 200 mm) required two treatment cycles for complete response (clearance rate: 100%). After a median follow-up of 24 months (range: 6-60 months) the overall effectiveness was 91.7%: 22/24 lesions remained in sustained complete remission. With the exception of a variable degree of hypopigmentation, the cosmetic outcome was satisfactory even for extensive lesions. Immunocryosurgery, is feasible and highly efficacious minimally-invasive treatment alternative for BD.

Cryosurgery during Imiquimod (Immunocryosurgery) for Periocular Basal Cell Carcinomas: An Efficacious Minimally Invasive Treatment Alternative

BACKGROUND/AIM

Periocular basal cell carcinomas (pBCC) remain a treatment challenge. Our aim was to retrospectively evaluate the feasibility and efficacy of immunocryosurgery for the treatment of pBCC.

METHODS

Immunocryosurgery is given in 5-week cycles of daily imiquimod, with cryosurgery on day 14. Patients treated between 1/1/2008 and 31/12/2014 were included in this study.

RESULTS

Immunocryosurgery was offered to 19 patients. Of these, 16 (i.e., 6 males and 10 females, average age 74.9 years, median tumor diameter 15 mm, range 5-60 mm), with 1 tumor each, were treated. Six tumors (37.5%) were relapses after surgery and 2 were of metatypical histology. All BCC were high risk for recurrence after treatment; 10 tumors had 2 risk factors for relapse, 5 had 3, and 1 had 4. The follow-up period ranged between 3 and 60 months (average 25.6 months). Of the 16 tumors treated, 14 (all with a diameter <40 mm) cleared with immunocryosurgery (total efficacy 87.5%); 7 out of 16 tumors (44%; all with a diameter ≤20 mm) cleared with 1 conventional 5-week immunocryosurgery treatment cycle. Seven additional tumors (including 2 with a diameter >20 mm) required intensified treatment schemes (of up to 10 weeks) for clearance. The 2 tumors that did not clear responded partially and were also the 2 largest ones (diameter 40 and 60 mm). Of the 14 cleared tumors, 2 relapsed during follow-up; 1 cleared with immunocryosurgery. At the last examination during follow-up, 13 out of 16 (81%) patients were in sustained clinical remission.

CONCLUSIONS

For most pBCC, immunocryosurgery is a feasible and efficacious alternative to surgical excision.

An Aggregate of Four Anthrax Cases during the Dry Summer of 2011 in Epirus, Greece

BACKGROUND

Human anthrax is currently a sporadic disease in Europe, without significant regional clustering.

OBJECTIVE

To report an unexpected aggregate of anthrax cases and correlate local climatic factors with yearly anthrax admissions.

METHODS

Clinical description of a geographical-temporal anthrax aggregate, correlation of disease admissions with local weather data in the period 2001-2014 and literature reports of anthrax clusters from Europe in the last 20 years.

RESULTS

We identified 5 cases, all cutaneous: an unexpected aggregate of 4 cases in mid-summer 2011 (including a probable human-to-human transmission) and a sporadic case in August 2005, all in relatively dry periods (p < 0.05). Remarkably, 3/6 reports of human anthrax aggregates from Europe were observed in Balkan Peninsula countries in the year 2011.

CONCLUSION

In the light of the predicted climatic change, unexpected anthrax aggregates during dry periods in southern Europe underscore the risk of future anthrax re-emergence on this continent.

Higher Serum Ferritin Levels Correlate with an Increased Risk of Cutaneous Morbidity in Adult Patients with β-Thalassemia: A Single-Center Retrospective Study

Disturbed iron homeostasis characterizes β-thalassemia and increases its morbidity. Our aim was to retrospectively associate β-thalassemia disease characteristics with treatment-requiring skin conditions. The files of adult β-thalassemia (including sickle β-thalassemia) patients were screened over a 10-year period for treatment-requiring skin disease episodes and their correlation with hematologic diagnoses and epidemiological and serological characteristics. Seventy-eight patients were identified, and 7 (9%) developed at least one relevant episode including cutaneous small-vessel vasculitis (CSVV), urticaria, and leg ulcers. Average ferritin serum level correlated significantly with development of a dermatosis (2,034 ± 799 μg/l in cases vs. 920 ± 907 μg/l in the overall population; p = 0.001, ANOVA). This difference relied exclusively on the high ferritin levels observed in patients with 'generalized' dermatoses (urticaria and CSVV: 3,860 ± 1,220 μg/l) as opposed to values within the normal range in the case of 'localized' ones (leg ulcers: 662 ± 167 μg/l). The employed iron chelation treatment influenced ferritin levels (p = 0.002, Kruskal-Wallis test) since chelation with a single agent seems to increase the risk of a skin disease (p = 0.013, likelihood ratio method). Conclusively, serum ferritin can be evaluated as risk factor for generalized dermatoses, but not for leg ulcers, in patients with the β-thalassemia genotype. This risk can be efficiently controlled with adequate chelation.

Advances in the in Vivo Raman Spectroscopy of Malignant Skin Tumors Using Portable Instrumentation

Raman spectroscopy has emerged as a promising tool for real-time clinical diagnosis of malignant skin tumors offering a number of potential advantages: it is non-intrusive, it requires no sample preparation, and it features high chemical specificity with minimal water interference. However, in vivo tissue evaluation and accurate histopathological classification remain a challenging task for the successful transition from laboratory prototypes to clinical devices. In the literature, there are numerous reports on the applications of Raman spectroscopy to biomedical research and cancer diagnostics. Nevertheless, cases where real-time, portable instrumentations have been employed for the in vivo evaluation of skin lesions are scarce, despite their advantages in use as medical devices in the clinical setting. This paper reviews the advances in real-time Raman spectroscopy for the in vivo characterization of common skin lesions. The translational momentum of Raman spectroscopy towards the clinical practice is revealed by (i) assembling the technical specifications of portable systems and (ii) analyzing the spectral characteristics of in vivo measurements.

Eye and Periocular Skin Involvement in Herpes Zoster Infection

Herpes zoster ophthalmicus (HZO) is a clinical manifestation of the reactivation of latent varicella zoster virus (VZV) infection and is more common in people with diminished cell-mediated immunity. Lesions and pain correspond to the affected dermatomes, mostly in first or second trigeminal branch and progress from maculae, papules to vesicles and form pustules, and crusts. Complications are cutaneous, visceral, neurological, ocular, but the most debilitating is post-herpetic neuralgia. Herpes zoster ophthalmicus may affect all the ophthalmic structures, but most severe eye-threatening complications are panuveitis, acute retinal necrosis (ARN) and progressive outer retinal necrosis (PORN) as well. Antiviral medications remain the primary therapy, mainly useful in preventing ocular involvement when begun within 72 hours after the onset of the rash. Timely diagnosis and management of HZO are critical in limiting visual morbidity. Vaccine in adults over 60 was found to be highly effective to boost waning immunity what reduces both the burden of herpes zoster (HZ) disease and the incidence of post-herpetic neuralgia (PHN).

Spatial fuzzy c-means algorithm with adaptive fuzzy exponent selection for robust vermilion border detection in healthy and diseased lower lips

INTRODUCTION

Accurate lip contour identification is demanding since variations in color, form and surface texture, even in normal lips, introduce artifacts in non-adapted segmentation algorithms. Herein, a method for vermilion border detection and quantification in healthy and diseased lower lips is presented.

AIM

To quantify the morphological irregularities of lower lip border, to validate its discriminative power in solar cheilosis diagnosis and to provide supportive tools toward, cost effective, non invasive, disease monitoring.

MATERIALS

Segmentation algorithm for lower lip border was based on spatial fuzzy c-means clustering algorithm with adaptive selection of fuzzy exponent m. Lip features measuring morphological lip border deviations were estimated. The method of lip border extraction and quantitative description was evaluated in a gold standard set of 25 young volunteers without onset of lip diseases. Quantitative descriptors were evaluated in terms of correct classification rates in differentiating 30 healthy control cases from 41 patients with solar cheilosis and were further applied to quantify the therapeutic outcome after immunocryosurgery in eight patients with solar cheilosis.

RESULTS

Adaptive estimation of fuzzy exponent m substantially boosted the segmentation quality in gold standard cases yielding quite smooth lip contours and uniformly low values of lip irregularity features. Discriminant analysis highlighted the distance between the extracted and modeled vermilion border as a feature with excellent diagnostic accuracy (sensitivity and specificity 98% and 93% respectively). Results on patients with solar cheilosis followed up after treatment with immunocryosurgery showed that proposed quantitative lip marker was able to trace the improvement of disease after treatment.

CONCLUSION

Correct lip border recognition is the prerequisite for extracting essential morphological descriptors from lips with epithelial diseases like solar cheilosis. In this paper we presented an efficient method for the automatic identification and quantitative description of lower lip vermilion border morphology in health and disease using digital photography and image analysis techniques.

Immunocryosurgery for non-superficial basal cell carcinoma: a pro-spective, open-label phase III study for tumours ≤ 2 cm in diameter

Cryosurgery and topical imiquimod are established mono-therapies for superficial basal cell carcinoma (BCC) but are often insufficient for thicker BCCs. We present here a phase III, prospective, interventional, single-arm (cases only) study (trial registration: NCT01212562) to evaluate the feasibility and efficacy of cryosurgery (liquid nitrogen, open spray, 2 × 15 s; day 14) during 5 weeks' imiquimod ("immunocryosurgery") for primary, non-superficial BCC, ≤ 2 cm in diameter. Ninety-one consecutive patients with 134 basal cell carcinoma were evaluated. A total of 83 patients (124 tumours) started treatment, and 79 patients (119 tumours) completed at least one cycle of immunocryosurgery (feasibility: 95.2%; follow-up: 18-60 months). The efficacy after one treatment cycle was 95 ± 2% stable complete remissions (116/119 tumours cleared, 3/116 tumours relapsed: 6 treat-ment "failures"). Neither tumour size (p = 0.865) nor localization (p = 0.233) predicted outcome. Repeat immunocryosurgery controlled 5/6 treatment failures (overall efficacy: 99%). Lack of a conventionally treated control group is a limitation of this study. However, the results show a high therapeutic efficacy of immunocryosurgery in a large series of primary non-superficial BCC.

Synthetic antimalarial drugs and the triggering of psoriasis - do we need disease-specific guidelines for the management of patients with psoriasis at risk of malaria?

BACKGROUND

Α distinct side effect of the synthetic quinolinic antimalarial drugs, still widely used for the treatment and prophylaxis of malaria, is the induction of psoriasis in predisposed or susceptible individuals.

OBJECTIVE

To describe two patients that had induction and exacerbation of psoriasis due to the administration of hydroxychloroquine, to adapt pertinent literature on the pathophysiology of this side effect, to review psoriasis-triggered cases by newer, non-quinolinic antimalarials, and to propose malaria treatment and prophylaxis guidelines for psoriatic patients.

PATIENTS AND METHODS

Two patients, a 40-year-old female with unknown history of psoriasis and a 37-year-old primigravida with an established history of psoriasis, were treated with hydroxychloroquine for a newly diagnosed lichen planopilaris and for an exacerbation of psoriatic arthritis, respectively. PubMed was searched (last accessed 20 October 2012) employing as search strategy the keywords (psoriasis) AND (drug), where "drug" is the name of each of the newer, non-quinolinic antimalarials.

RESULTS

Psoriasis was controlled in both patients. The primigravida gave birth to a healthy child at 39 weeks of gestation. The literature review returned no articles that linked the newer antimalarials with psoriasis.

CONCLUSION

Despite the increased awareness, antimalarials-triggered psoriasis is still diagnosed. Fortunately, the current artemisinin-based antimalarial treatment can be safely offered to susceptible individuals. Additionally, prophylaxis with doxycycline or the combination atovaquone-proguanil could be a safe suggestion for malaria prophylaxis in psoriatic patients.

Skin diseases associated with Malassezia yeasts: facts and controversies

The implication of the yeast genus Malassezia in skin diseases has been characterized by controversy, since the first description of the fungal nature of pityriasis versicolor in 1846 by Eichstedt. This is underscored by the existence of Malassezia yeasts as commensal but also by their implication in diseases with distinct absence of inflammation despite the heavy fungal load (pityriasis versicolor) or with characteristic inflammation (eg, seborrheic dermatitis, atopic dermatitis, folliculitis, or psoriasis). The description of 14 Malassezia species and subsequent worldwide epidemiologic studies did not reveal pathogenic species but rather disease-associated subtypes within species. Emerging evidence demonstrates that the interaction of Malassezia yeasts with the skin is multifaceted and entails constituents of the fungal wall (melanin, lipid cover), enzymes (lipases, phospholipases), and metabolic products (indoles), as well as the cellular components of the epidermis (keratinocytes, dendritic cells, and melanocytes). Understanding the complexity of their interactions will highlight the controversies on the clinical presentation of Malassezia-associated diseases and unravel the complexity of skin homeostatic mechanisms.

Office-based treatment of basal cell carcinoma with immunocryosurgery: feasibility and efficacy

INTRODUCTION

Minimally invasive, non-surgical, office-based modalities are a welcome alternative to surgery for basal cell carcinoma(BCC). This study evaluates the treatment of BCC with immunocryosurgery (cryosurgery during topical imiquimod) in a dermatology office setting.

METHODS

Response of BCC to immunocryosurgery (daily imiquimod for 5 weeks and a liquid N2 cryosurgery session at the end of the 2nd week) was evaluated according to treatment feasibility, tumor clearance, and relapse.

RESULTS

Twenty-four patients with a total of 36 BCC (four relapses after cryosurgery or surgery) were recruited and all finished treatment (follow-up: 2-24 months). One month after the end of treatment, 30/36 sites were clinically cured. In five cases, a repeat cryosurgery at this time led to clinical cure (one patient refused cryosurgery; overall cure rate: 97.2%). Two relapses occurred after 12 and 14 months follow-up, which were successfully treated with immunosurgery and cryosurgery, respectively. Adverse effects included hypopigmentation, redness persisting for up to 3 months after treatment, superficial scarring that improved with time, and worry during treatment because of skin irritation (resolved with a phone discussion in all cases).

CONCLUSION

Immunocryosurgery is a feasible and efficacious procedure that can be performed at a dermatology office for the treatment of primary and relapsed BCC.

Gray Hausdorff distance measure for medical image comparison in dermatology: Evaluation of treatment effectiveness by image similarity

INTRODUCTION

In clinical dermatology, the stabilization of the overall skin condition can be in many cases the earliest qualitative measure of the effectiveness of the therapeutic intervention. Subjective image comparisons, that offer empirical 'qualitative' judgments of degrees of image similarities, are traditionally employed by the involved physicians.

OBJECTIVES

To quantify, by means of an image similarity metric, the degree of stabilization of an expanding skin disease, and to identify the situation of 'no further change' of the skin condition of the patient, providing thus the physician with an early, objective measure of the efficacy of the used therapy.

METHODS

For treatment assessment, a variant of gray Hausdorff distance metric was employed to compare images of lesional skin segments of a patient, taken at different time points during a therapeutic course. Prior to image comparison, an effective preprocessing scheme was adapted to constrain wide pose and light variations. The proposed similarity algorithm was tested on raw clinical image data sets of patients diagnosed with toxic epidermal necrolysis, a life-threatening condition with rapid evolution. Fine tuning of algorithm's parameters was optimized using Precision-Recall curves.

RESULTS

Proposed image comparison method resulted in a high-degree of image similarity (about 96%) between pictures taken at second and fifth day of hospitalization. Current similarity results substantiate a significant agreement between the computer-treatment assessment, by means of image comparison, and the corresponding clinical experts' review of skin condition.

CONCLUSION

Objective evidence of 'no further change' situation may provide (a) intuitive clinical decision support to dermatologists in assessing aggressive skin conditions, where the timely evaluation of treatment response is of vital importance and (b) a versatile end-point measure for corresponding therapeutic clinical trials.

Phospholipase activity after β-endorphin exposure discriminates Malassezia strains isolated from healthy and seborrhoeic dermatitis skin

BACKGROUND

Phospholipase activity and its induction by β-endorphin have been associated with pathogenic Malassezia pachydermatis animal isolates.

OBJECTIVE

To evaluate Malassezia phosholipase activity in human isolates from seborrhoeic dermatitis (SD) and healthy controls before and after β-endorphin exposure.

METHODS

Eighty-four volunteers with or without SD (N = 41) were sampled. Isolated Malassezia strains were incubated in Dixon's medium with and without 100 nmol/L β-endorphin. Subsequently, phospholipase activity was assessed in egg-yolk agar and the results were compared employing Wilcoxon sign test for paired data, chi-squared test and multinomial logistic regression analysis.

RESULTS

A total of 64 Malassezia strains were isolated. SD strains tended to have decreased phospholipase activity before (P = 0.057) and increased after exposure to β-endorphin (P = 0.061) compared to isolates from healthy skin. Phospholipase activity after β-endorphin exposure related to basal enzyme activity as a measure of per strain phospholipase inducibility by β-endorphin did not depend on Malassezia species (P = 0.652). However, this latter biochemical trait discriminates strains isolated from SD lesional and healthy skin (P = 0.036).

CONCLUSION

β-endorphin exposure modifies the in vitro phosholipase activity in Malassezia species isolated from SD lesional skin. This is in accordance with emerging evidence that enhanced local lipase activity is involved in the pathogenesis of SD.