The life-threatening complications of dermatologic therapies

Amebiasis as a sexually transmitted infection: A re-emerging health problem in developed countries

Amebiasis, which is caused by Entamoeba histolytica (E. histolytica), is the second leading cause of parasite-related death worldwide. It manifests from asymptomatic carriers to severe clinical conditions, like colitis and liver abscesses. Amebiasis is commonly seen in developing countries, where water and food are easily contaminated by feces because of the poor sanitation. However, a recently challenge in many developed countries is the increase in domestic cases of invasive amebiasis as a sexually transmitted infection (STI amebiasis). In contrast to food-/ waterborne transmission of E. histolytica in developing countries, transmission of STI amebiasis occurs directly through human-to-human sexual contact (e.g., men who have sex with men and people who engage in oral-anal sex); in this setting, asymptomatic infected individuals are the main reservoir of E. histolytica. The Development of screening methods for the early diagnosis of asymptomatic E. histolytica infection is the key to epidemiologic control. Moreover, delay in diagnosis of severe cases (e.g., fulminant amebiasis) leads to death even in developed countries. It is also important to increase clinical awareness of domestically transmitted STI amebiasis in the clinical settings. This review considers the changing epidemiology and clinical manifestations of STI amebiasis, and finally discusses the future strategies for the better practice.

Inhibitory activity and mechanism of silver nanoparticles against herpes simplex virus type 1

Herpes simplex virus type 1 (HSV-1) is a common pathogen that infects 50-90% of the world's population and causes a variety of diseases, some of which can be life-threatening. Silver nanoparticles (AgNPs) have been shown to have broad-spectrum antiviral activity. In this study, we investigated the activity of AgNPs against HSV-1 and found that AgNPs effectively inhibited plaque formation and HSV-1 progeny production, reduced the genomic load, and interfered with HSV-1 mRNA expression and protein synthesis. Transmission electron microscopy showed that AgNPs interacted with HSV-1 and altered the shape of the viral particles. Furthermore, AgNPs affected the entry of HSV-1 into cells as well as their release and cell-to-cell spread. AgNPs were also found to downregulate the expression of pro-inflammatory cytokines upon HSV-1 infection. Combined treatment with AgNPs and acyclovir (ACV) confirmed that AgNPs significantly enhanced the inhibitory effect of ACV against HSV-1. Our findings may contribute to an understanding of the mechanism of the antiviral effect of AgNPs against HSV-1 and help to provide a theoretical basis for their clinical application.

Endometriosis Susceptibility to Dapsone-Hydroxylamine-Induced Alterations Can Be Prevented by Licorice Intake: In Vivo and In Vitro Study

Endometriosis, an estrogen-dependent chronic gynecological disease, is characterized by a systemic inflammation that affects circulating red blood cells (RBC), by reducing anti-oxidant defenses. The aim of this study was to investigate the potential beneficial effects of licorice intake to protect RBCs from dapsone hydroxylamine (DDS-NHOH), a harmful metabolite of dapsone, commonly used in the treatment of many diseases. A control group (CG, n = 12) and a patient group (PG, n = 18) were treated with licorice extract (25 mg/day), for a week. Blood samples before (T₀) and after (T₁) treatment were analyzed for: i) band 3 tyrosine phosphorylation and high molecular weight aggregates; and ii) glutathionylation and carbonic anhydrase activity, in the presence or absence of adjunctive oxidative stress induced by DDS-NHOH. Results were correlated with plasma glycyrrhetinic acid (GA) concentrations, measured by HPLC–MS. Results showed that licorice intake decreased the level of DDS-NHOH-related oxidative alterations in RBCs, and the reduction was directly correlated with plasma GA concentration. In conclusion, in PG, the inability to counteract oxidative stress is a serious concern in the evaluation of therapeutic approaches. GA, by protecting RBC from oxidative assault, as in dapsone therapy, might be considered as a new potential tool for preventing further switching into severe endometriosis.

[Demodex and ocular surface disease]

Demodex is a saprophytic mite of the ocular adnexa, which can in certain circumstances proliferate on the skin of the face and on the eyelid margins. It is involved in facial rosacea (especially in the papulopustular form) and in the development or aggravation of anterior and/or posterior blepharitis or even keratoconjunctivitis, often in association with cutaneous lesions ; the pathophysiology is often multifactorial. Symptoms are non-specific, but the presence of cylindrical sleeves on the eyelashes is very suggestive of infestation, and certain techniques of biomicroscopic examination or imaging, such as confocal microscopy in vivo, allow direct visualization of the parasite. Parasitological examination of the eyelashes can confirm the diagnosis and can be improved by good sampling technique. Eyelid hygiene and oil-based ointments are the cornerstone of treatment. New specific treatments, in particular topical treatments based on tea tree oil, ivermectin, as well as pulsed light therapy and micro-exfoliation of the eyelid margin, can help to reduce the parasitic load and improve symptoms.

Safety of current therapies for onychomycosis

INTRODUCTION

Onychomycosis is the most common nail disease seen in clinical practice. Treatment options include systemic and topical therapies, as well as devices. Following clinical and mycologic diagnosis, treatment must be individualized, accounting for disease severity, infecting organism(s), comorbidities, patient characteristics and drug/device efficacy. Safety is the most important consideration in choosing the most appropriate therapeutic modality.

AREAS COVERED

This review covers currently available treatments for onychomycosis, with an emphasis on safety and tolerability. Medications and devices were analyzed for side effects, drug-drug interactions, and safety during pregnancy and breastfeeding.

EXPERT OPINION

Systemic antifungals offer greater efficacy for onychomycosis treatment but are limited by risks of systemic toxicity and drug-drug interactions. The risk of terbinafine-induced hepatotoxicity is negligible in healthy patients. Systemic therapies, especially azole antifungals, are associated with numerous drug-drug interactions, some of which are life-threatening and fatal. Thus, a detailed medication history is critical before prescribing these medications. Topical antifungals are well tolerated and generally safe, with only potential local side effects. Systemic and topical onychomycosis treatments should not be prescribed during pregnancy and breastfeeding. Laser therapy is likely less effective than systemic and topical therapies, but may be safely used during pregnancy and breastfeeding.

Inhibition of herpes simplex virus type 1 by copper oxide nanoparticles

There are accumulating reports of the emergence of drug-resistant strains of HSV-1 that have become a barrier to successful treatment of HSV-1 infection. Therefore, there is a pressing need to identify and evaluate alternative antiherpetic agents. The aim of the present study was to investigate the effect of copper oxide nanoparticles (CuO-NPs) on HSV-1 infection. The MTT assay was applied to examine the cytotoxic effects of CuO-NPs on Vero cells. Antiherpetic potency was determined using the TCID50 and quantitative Real-Time PCR assays. To evaluate the inhibitory impact of CuO-NPs on the expression of viral antigens, an indirect immunofluorescence assay (IFA) was performed. Acyclovir was used as a reference drug in all experiments. Exposure of HSV-1 with CuO-NPs at the highest non-toxic concentration (100 μg/mL) resulted in 2.8 log10 TCID50 reduction in infectious virus titer as compared with virus control (P < 0.0001). This concentration of CuO-NPs was associated with 83.3% inhibition rate, which was estimated based on the HSV-1 viral load compared to virus control. Our findings demonstrated that CuO-NPs are associated with a significant antiviral potency against HSV-1. This feature shows strong potential for CuO-NPs to be used in topical formulations for the treatment of orolabial or genital herpetic lesions.

Dapsone hydroxylamine-mediated alterations in human red blood cells from endometriotic patients

Endometriosis, an estrogen-dependent chronic gynecological disease in women of reproductive age, is characterized by a systemic inflammation status involving also red blood cells (RBCs). In this study, we evaluated how the protein oxidative status could be involved in the worsening of RBC conditions due to dapsone intake in endometriotic women in potential treatment for skin or infection diseases. Blood samples from two groups of volunteers, control group (CG) and endometriosis patient group (PG), were analyzed for their content of band 3 tyrosine phosphorylation (Tyr-P) and high molecular weight aggregate (HMWA) in membranes, and glutathione (GSH) content and carbonic anhydrase (CA) activity in cytosol. In endometriotic patients, RBC showed the highest level of oxidative-related alterations both in membrane and cytosol. More interestingly, the addition of dapsone hydroxylamine (DDS-NHOH) could induce further increase of both membranes and cytosol markers, with an enhancement of CA activity reaching about 66% of the total cell enzyme amount. In conclusion, in PG the systemic inflammatory status leads to the inability of counteracting adjunctive oxidative stress, with a potential involvement of CA-related pathologies, such as glaucoma. Hence, the importance of the evaluation of therapeutic approaches worsening oxidative imbalance present in PG RBC is underlined.

Chemical composition and anti-herpes simplex virus type 1 (HSV-1) activity of extracts from Cornus canadensis

BACKGROUND

Many plants of boreal forest of Quebec have been used by Native Americans to treat a variety of microbial infections. However, the antiviral activities of these plants have been seldom evaluated on cellular models to validate their in vitro efficiencies. In this study, Cornus canadensis L. (Cornaceae), a plant used in Native American traditional medicine to treat possible antiviral infections, has been selected for further examination.

METHODS

The plant was extracted by decoction and infusion with water, water/ethanol 1:1 and ethanol to obtain extracts similar to those used by Native Americans. The effects of the extracts were tested on herpes simplex virus type-1 (HSV-1) using a plaque reduction assay. Moreover, bioassay-guided fractionation was achieved to isolate bioactive compounds.

RESULTS

Water/ethanol 1:1 infusion of C. canadensis leaves were the most active extracts to inhibit virus absorption with EC₅₀ of about 9 μg mL^-1, whereas for direct mode, both extraction methods using water or water/ethanol 1:1 as solvent were relatively similar with EC₅₀ ranging from 11 to 17 μg mL^-1. The fractionation led to the identification of active fractions containing hydrolysable tannins. Tellimagrandin I was found the most active compound with an EC₅₀ of 2.6 μM for the direct mode and 5.0 μM for the absorption mode.

CONCLUSION

Altogether, the results presented in this work support the antiviral activity of Cornus canadensis used in Native American traditional medicine.

Neurological and Neuropsychiatric Adverse Effects of Dermatologic Medications

Severe, recalcitrant dermatologic conditions often require systemic treatment. Although efficacious, these medications have been associated with wide-ranging adverse reactions. Some are reversible, predictable, and either dose-dependent or treatment length-dependent, while others are unpredictable, irreversible, and potentially fatal. This review examines the neuropsychiatric adverse effects associated with US FDA-approved medications for treatment of the following dermatologic pathologies that typically require systemic therapy: autoimmune dermatoses, acne, psoriasis, and melanoma. A search of the literature was performed, with adverse effects ranging from mild headaches and neuropathy to severe encephalopathies. The medications associated with the most serious reactions were those used to treat psoriasis, especially the older non-biologic medications such as cyclosporine A and methotrexate. Given the importance of these systemic dermatologic therapies in treating severe, recalcitrant conditions, and the wide variety of potentially serious neuropsychiatric adverse effects of these medications, neurologists, psychiatrists, dermatologists, oncologists, and primary care providers must be aware of the potential for these neuropsychiatric adverse reactions to allow for appropriate counseling, management, and medication withdrawal.

The Comparative Safety of Multiple Alternative Agents in Refractory Chronic Urticaria Patients

BACKGROUND

Patients who have failed traditional treatment of chronic urticaria may require trials of alternative medications. Safety profiles, continuous laboratory monitoring, and physician comfort are often barriers to treatment.

OBJECTIVES

To evaluate the safety of alternative agents used in chronic urticaria.

METHODS

A retrospective chart review of electronic medical records from a single-center allergy and immunology clinic in a major academic hospital was conducted. One hundred twenty-six charts of patients with chronic urticaria treated with alternative agents were reviewed.

RESULTS

Adverse effects were reported in 39 of 73 (53%) patients on dapsone, 19 of 47 (40%) patients on sulfasalazine, 15 of 36 (42%) patients on tacrolimus, 7 of 45 (16%) patients on hydroxychloroquine, 9 of 27 (33%) patients on mycophenolate, 6 of 8 (75%) patients on cyclosporine, and 3 of 24 (4%) patients on omalizumab. Most of these adverse effects were mild, did not require discontinuation of the medication, and resolved after stopping the medication or decreasing the dose.

CONCLUSIONS

The use of alternative agents for the treatment of chronic urticaria angioedema is generally safe when proper laboratory and clinical monitoring is observed.

Genetic risk factors for drug-induced liver injury in rheumatoid arthritis patients using low-dose methotrexate

Low-dose methotrexate (MTX) is part of the mainstay of rheumatoid arthritis treatment. Hepatotoxicity is among the most feared side effects of low-dose MTX and is associated with increased morbidity. At present, histological evaluation of liver biopsies is the gold standard to retrospectively diagnose MTX-induced liver damage. Genetic markers present an interesting opportunity to preemptively identify patients at risk for MTX-induced hepatotoxicity. Here, we will review the literature on candidate genetic markers for the risk of MTX-induced hepatotoxicity. These candidate genetic markers include polymorphisms in the gene encoding the enzyme MTHFR.

Diagnosis and treatment of urticaria and angioedema: a worldwide perspective

: Urticaria and angioedema are common clinical conditions representing a major concern for physicians and patients alike. The World Allergy Organization (WAO), recognizing the importance of these diseases, has contributed to previous guidelines for the diagnosis and management of urticaria. The Scientific and Clinical Issues Council of WAO proposed the development of this global Position Paper to further enhance the clinical management of these disorders through the participation of renowned experts from all WAO regions of the world. Sections on definition and classification, prevalence, etiology and pathogenesis, diagnosis, treatment, and prognosis are based on the best scientific evidence presently available. Additional sections devoted to urticaria and angioedema in children and pregnant women, quality of life and patient-reported outcomes, and physical urticarias have been incorporated into this document. It is expected that this article will supplement recent international guidelines with the contribution of an expert panel designated by the WAO, increasing awareness of the importance of urticaria and angioedema in medical practice and will become a useful source of information for optimum patient management worldwide.

Neuromuscular adverse effects associated with systemic retinoid dermatotherapy: monitoring and treatment algorithm for clinicians

Although neuromuscular adverse effects represent significant clinical manifestations of hypervitaminosis A syndrome, surprisingly little attention has been paid to the potential neuromuscular toxicity of vitamin A derivatives (retinoids). Since isotretinoin and acitretin are currently the two most commonly used oral retinoids in systemic dermatotherapy, this review focuses exclusively on their neuromuscular adverse effects and proposes a neuromuscular algorithm for appropriate monitoring of patients treated with these two compounds. The most frequent CNS adverse effect associated with oral isotretinoin is headache, either as an independent adverse effect or as part of benign intracranial hypertension, which is additionally characterized by nausea and visual changes. Isolated cases of stiff-person-like syndrome, epileptic seizures and generalized muscle stiffness syndrome, possibly or probably related to oral treatment with isotretinoin, have also been reported. In addition, oral isotretinoin has reportedly been associated with muscular adverse effects that most frequently manifest as myalgia and stiffness and, in rare cases, as true myopathy or rhabdomyolysis. Creatine phosphokinase, a specific marker of muscle destruction, has been found to be elevated, occasionally by up to 100 times the normal value (with or without muscular symptoms and signs), in a variable percentage of patients receiving isotretinoin treatment and particularly in those undergoing vigorous physical exercise. Oral acitretin has been found to cause peripheral nerve dysfunction, particularly of sensory fibres, which in rare cases leads to clinically evident sensory disturbances. Less clear is the causal relationship between acitretin and benign intracranial hypertension or myopathy, whereas an isolated case of cranial nerve IV (oculomotor) palsy and a further case of thrombotic stroke during treatment with oral acitretin have been reported. Systemic diseases with involvement of nervous and/or muscle tissue and neuromuscular disorders should be regarded as exclusion criteria for initiation of oral retinoid therapy. Additionally, intense physical exercise and concurrent treatment with neurotoxic or myotoxic drugs should be avoided during treatment with oral retinoids. In order to minimize the potential risk of neuromuscular adverse effects, a neuromuscular algorithm is suggested that may be useful for monitoring patients taking oral retinoids.

Treatment of psoriasis in patients with hepatitis C: from the Medical Board of the National Psoriasis Foundation

BACKGROUND

Treating psoriasis in patients with concomitant hepatitis C virus (HCV) infection presents a special challenge. Not only is psoriasis exacerbated by interferon therapy, the standard of care for HCV, but many psoriasis therapies are potentially hepatotoxic, immunosuppressive, or both, which has been generally thought to be a contraindication in chronic infections such as HCV.

OBJECTIVE

Our aim was to arrive at a consensus on treating psoriasis in patients with concomitant HCV infection.

METHODS

Reports in the literature were reviewed regarding common psoriasis therapies and liver toxicity.

RESULTS

Topical therapies are first-line therapy for patients with limited psoriasis and HCV. Ultraviolet B phototherapy may be considered as a second-line treatment when needed. Ultraviolet B phototherapies in combination with topical therapies are first line for patients with moderate to severe psoriasis, and are considered safe in those patients with concomitant HCV infection. Other systemic therapies, such as acitretin, etanercept, and, possibly, other tumor necrosis factor inhibitors, are considered second line. Psoralen plus ultraviolet A should also be considered a second-line therapy.

LIMITATIONS

There are few evidence-based studies on treating psoriasis with systemic therapy in patients with pre-existing liver disease.

CONCLUSIONS

There are no large double-blind clinical trials addressing the treatment of psoriasis in patients with HCV infection and more studies are needed.

Role of epidermal dendritic cells in drug-induced cutaneous adverse reactions

Drug-induced adverse reactions (ADR) include any undesirable pharmacological effect that occurs following drug administration at therapeutic doses. The appearance of ADR significantly limits the use of drugs in as much as their clinical symptoms may range from very mild discomfort such as cutaneous rash, up to very severe, or even fatal tissue necrolysis such as the Stevens Johnson syndrome.One of the most frequently involved organ during ADR is the skin. Drug-induced cutaneous reactions (CDR) incidence is variable but they may appear in 2-3% of ambulatory patients, and it may increase to 10-15% when patients are hospitalized, or even be as high as 60% when co morbidity includes the presence of virus, bacteria, or parasites.Due to the fact that skin is one of the organs most frequently involved in ADR, in this work we analyze and propose a mechanism by which epidermal dendritic cells operating as the sentinels of the skin neuro-immune-endocrine system may contribute to CDR via either immunogenic or tolerogenic immune responses towards drugs, whenever they are administered topic or systemically.

Methotrexate and liver function: a study of 13 psoriasis cases treated with different cumulative dosages

BACKGROUND

The need and frequency of hepatic biopsies during methotrexate (MTX) therapy are still controversial.

OBJECTIVES

The purpose of this investigation is to assess MTX liver toxicity in patients with psoriasis through percutaneous liver biopsy, and compare liver morphology changes with increasing cumulative dosages (1, 2, 3 and 4 g) of MTX.

RESULTS

Cumulative dosages of 1 to 2 g MTX did not cause significant liver toxicity. From a cumulative dosage of 3 to 4 g, there is fibrosis formation, inflammation enhancement in the portal area and fibrous septa, configuring regenerative nodes.

CONCLUSION

In patients with no risk factors for liver disease, with normal physical examination and liver tests, biopsy can be done after a cumulative MTX dosage of approximately 1 to 1.5 g and repeated for each gram. In patients with risk factors, liver biopsy should be done before use of MTX, or within the first 2 months of treatment at the most, and repeated for each gram of cumulative dosage.

Prospective tracing of MLL-FRYL clone with low MEIS1 expression from emergence during neuroblastoma treatment to diagnosis of myelodysplastic syndrome

We prospectively observed a child exposed to intensive multimodality therapy for metastatic neuroblastoma from emergence of a MLL translocation to disease diagnosis. The t(4;11)(p12;q23) was detected in the marrow 17 months after starting treatment following topoisomerase II poisons, alkylating agents, local radiation, hematopoietic stem cell transplantation, anti-GD2 monoclonal antibody with granulocyte macrophage-colony-stimulating factor, and a high cumulative dose of oral etoposide. Reciprocal genomic breakpoint junctions and fusion transcripts joined MLL with FRYL, the Drosophila melanogaster protein homologue of which regulates cell fate. Etoposide metabolites induced topoisomerase II cleavage complexes that could form both breakpoint junctions. Cells harboring the translocation replaced the marrow without clinical evidence of leukemia and differentiation appeared unaffected for 37 months. Subsequent bilineage dysplasia and increased blasts in addition to the translocation fulfilled criteria for MDS. The MEIS1 target gene of typical MLL fusion oncoproteins was underexpressed before and at MDS diagnosis. These results are consistent with repair of topoisomerase II cleavage from etoposide metabolites as the translocation mechanism, whereas other agents in the regimen may have contributed to progression of the clone with the translocation to MDS. MLL-FRYL did not increase MEIS1 expression, conferred a proliferative advantage without altering differentiation, and had protracted latency to disease.

Bullous pemphigoid treatment review

Bullous pemphigoid is an autoimmune skin blistering disorder that can present with several different degrees of severity. The treatment modality employed by the treating physician varies from localised topical therapy and anti-inflammatory treatments with minimal side effects to immunosuppressive agents associated with significant adverse reactions. Deciding which therapy to use with a particular patient can be a challenge, and the treating physician must take into account the severity of disease, the overall medical condition of the patient and potential drug interactions. This article provides a comprehensive review of current medical therapies, as well as an overall approach to the patient with bullous pemphigoid.