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Cerqueira ARA, Rodrigues L, Coavoy-Sánchez SA, Teixeira SA, Feitosa KB, Taniguchi EY, Lopes LR, Cassola AC, Muscará MN, Sá-Nunes A, Costa SKP. Aedes aegypti salivary gland extract alleviates acute itching by blocking TRPA1 channels. Front Physiol 2023; 14:1055706. [PMID: 37441000 PMCID: PMC10333701 DOI: 10.3389/fphys.2023.1055706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 06/12/2023] [Indexed: 07/15/2023] Open
Abstract
Aedes aegypti (Ae. aegypti) saliva induces a variety of anti-inflammatory and immunomodulatory activities. Interestingly, although it is known that mosquito bites cause allergic reactions in sensitised hosts, the primary exposure of humans to Ae. aegypti does not evoke significant itching. Whether active components in the saliva of Ae. aegypti can counteract the normal itch reaction to injury produced by a histaminergic or non-histaminergic pathway in vertebrate hosts is unknown. This study investigated the effects of Ae. aegypti mosquito salivary gland extract (SGE) on sensitive reactions such as itching and associated skin inflammation. Acute pruritus and plasma extravasation were induced in mice by the intradermal injection of either compound 48/80 (C48/80), the Mas-related G protein-coupled receptor (Mrgpr) agonist chloroquine (CQ), or the transient receptor potential ankyrin 1 (TRPA1) agonist allyl isothiocyanate (AITC). The i.d. co-injection of Ae. aegypti SGE inhibited itching, plasma extravasation, and neutrophil influx evoked by C48/80, but it did not significantly affect mast cell degranulation in situ or in vitro. Additionally, SGE partially reduced CQ- and AITC-induced pruritus in vivo, suggesting that SGE affects pruriceptive nerve firing independently of the histaminergic pathway. Activation of TRPA1 significantly increased intracellular Ca2+ in TRPA-1-transfected HEK293t lineage, which was attenuated by SGE addition. We showed for the first time that Ae. aegypti SGE exerts anti-pruriceptive effects, which are partially regulated by the histamine-independent itch TRPA1 pathway. Thus, SGE may possess bioactive molecules with therapeutic potential for treating nonhistaminergic itch.
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Affiliation(s)
- Anderson R. A. Cerqueira
- Departamento de Farmacologia, Instituto de Ciências Biomédicas, Universidade de São Paulo, São Paulo, Brazil
| | - Leandro Rodrigues
- Departamento de Farmacologia, Instituto de Ciências Biomédicas, Universidade de São Paulo, São Paulo, Brazil
| | | | - Simone A. Teixeira
- Departamento de Farmacologia, Instituto de Ciências Biomédicas, Universidade de São Paulo, São Paulo, Brazil
| | - Karla B. Feitosa
- Departamento de Farmacologia, Instituto de Ciências Biomédicas, Universidade de São Paulo, São Paulo, Brazil
| | - Erika Y. Taniguchi
- Departamento de Fisiologia e Biofísica, Instituto de Ciências Biomédicas, Universidade de São Paulo, São Paulo, Brazil
| | - Lucia R. Lopes
- Departamento de Farmacologia, Instituto de Ciências Biomédicas, Universidade de São Paulo, São Paulo, Brazil
| | - Antônio C. Cassola
- Departamento de Fisiologia e Biofísica, Instituto de Ciências Biomédicas, Universidade de São Paulo, São Paulo, Brazil
| | - Marcelo N. Muscará
- Departamento de Farmacologia, Instituto de Ciências Biomédicas, Universidade de São Paulo, São Paulo, Brazil
| | - Anderson Sá-Nunes
- Departamento de Imunologia, Instituto de Ciências Biomédicas, Universidade de São Paulo, São Paulo, Brazil
- Instituto Nacional de Ciência e Tecnologia em Entomologia Molecular, Conselho Nacional de Desenvolvimento Científico e Tecnológico (INCT-EM/CNPq), Rio de Janeiro, Brazil
| | - Soraia K. P. Costa
- Departamento de Farmacologia, Instituto de Ciências Biomédicas, Universidade de São Paulo, São Paulo, Brazil
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Jin J, Li L, Wang Y, Li K, Qian A, Li W, Liu Q, Wen C, Liu Q, Yan G, Xue F. Estrogen alleviates acute and chronic itch in mice. Exp Ther Med 2023; 25:255. [PMID: 37153887 PMCID: PMC10155243 DOI: 10.3892/etm.2023.11954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 02/23/2023] [Indexed: 05/10/2023] Open
Abstract
Itching is associated with various skin diseases, including atopic dermatitis and allergic dermatitis, and leads to repeated scratching behavior and unpleasant sensation. Although clinical and laboratory research data have shown that estrogen is involved in regulating itch, the molecular and cellular basis of estrogen in itch sensation remains elusive. In the present study, it was found that estrogen-treated mice exhibited reduced scratching bouts when challenged with histamine, chloroquine, the proteinase-activated receptor-2 activating peptide SLIGRL-NH2 (SLIGRL), compound 48/80, and 5-hydroxytryptamine when compared with mice in the placebo group. Moreover, estrogen also suppressed scratching bouts in the mouse model of chronic itch induced by acetone-ether-water treatment. Notably, consistent with the behavioral tests, the present RNA-seq analysis showed that estrogen treatment caused significantly reduced expression levels of itch-related molecules such as Mas-related G-protein coupled receptor member A3, neuromedin B and natriuretic polypeptide b. In addition, estradiol attenuated histamine-induced and chloroquine-induced calcium influx in dorsal root ganglion neurons. Collectively, the data of the present study suggested that estrogen modulates the expression of itch-related molecules and suppresses both acute and chronic itch in mice.
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Affiliation(s)
- Jinhua Jin
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100144, P.R. China
| | - Li Li
- Department of Anatomy, Yanbian University of Medicine, Yanji, Jilin 133002, P.R. China
| | - Yuhui Wang
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100144, P.R. China
| | - Keyan Li
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100144, P.R. China
| | - Aihua Qian
- Department of Gastroenterology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200025, P.R. China
| | - Weiou Li
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100144, P.R. China
| | - Qing Liu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing 100053, P.R. China
| | - Chao Wen
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100144, P.R. China
| | - Quanle Liu
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100144, P.R. China
| | - Guanghai Yan
- Department of Anatomy, Yanbian University of Medicine, Yanji, Jilin 133002, P.R. China
- Correspondence to: Dr Fushan Xue, Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, 95 Yong-An Road, Xi-Cheng, Beijing 100050, P.R. China
| | - Fushan Xue
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, P.R. China
- Correspondence to: Dr Fushan Xue, Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, 95 Yong-An Road, Xi-Cheng, Beijing 100050, P.R. China
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Kim BS, Inan S, Ständer S, Sciascia T, Szepietowski JC, Yosipovitch G. Role of kappa-opioid and mu-opioid receptors in pruritus: Peripheral and central itch circuits. Exp Dermatol 2022; 31:1900-1907. [PMID: 36054458 PMCID: PMC10087456 DOI: 10.1111/exd.14669] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 08/03/2022] [Accepted: 08/15/2022] [Indexed: 12/14/2022]
Abstract
Modern genetic approaches in animal models have unveiled novel itch-specific neural pathways, emboldening a paradigm in which drugs can be developed to selectively and potently target itch in a variety of chronic pruritic conditions. In recent years, kappa-opioid receptors (KORs) and mu-opioid receptors (MORs) have been implicated in both the suppression and promotion of itch, respectively, by acting on both the peripheral and central nervous systems. The precise mechanisms by which agents that modulate these pathways alleviate itch remains an active area of investigation. Notwithstanding this, a number of agents have demonstrated efficacy in clinical trials that influence both KOR and MOR signalling. Herein, we summarize a number of opioid receptor modulators in development and their promising efficacy across a number of chronic pruritic conditions, such as atopic dermatitis, uremic pruritus and beyond.
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Affiliation(s)
- Brian S Kim
- Kimberly and Eric J. Waldman Department of Dermatology, Mark Lebwohl Center for Neuroinflammation and Sensation, Marc and Jennifer Lipschultz Precision Immunology Institute, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Saadet Inan
- Center for Substance Abuse Research, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Sonja Ständer
- Department of Dermatology and Center for Chronic Pruritus, University Hospital Műnster, Műnster, Germany
| | | | - Jacek C Szepietowski
- Department of Dermatology, Venereology, and Allergology, Wroclaw Medical University, Wroclaw, Poland
| | - Gil Yosipovitch
- Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, Miami Itch Center, Miller School of Medicine, University of Miami, Miami, Florida, USA
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Gael M, Adam T, Mariano-Bourin M, Bursztejn AC. Efficacy of dupilumab in chronic prurigo and chronic idiopathic pruritus: A systematic review of current evidence and analysis of response predictors. J Eur Acad Dermatol Venereol 2022; 36:1541-1551. [PMID: 35569006 DOI: 10.1111/jdv.18221] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 04/21/2022] [Indexed: 11/28/2022]
Abstract
Dupilumab has demonstrated a great reduction on chronic pruritus that is the hallmark of atopic dermatitis (AD). Underscoring relevant pathogenesis similarities emerging from AD, chronic idiopathic pruritus (CIP) and chronic prurigo (CP), several authors suggested the beneficial role of dupilumab in these conditions. The evidence on this subject is limited with no precise data available. In this study, we carried out a systematic literature review in order to evaluate the efficacy of dupilumab on both pruritus and skin manifestations in the two largest retrospective cohorts of patients with CP and CIP and tried to identify potential response predictors. Electronic searches were conducted on 4 databases. Our primary outcome was the improvement in pruritus measured by a reduction in patient's reported numerical rating scale of itch (NRSI) by > 4. Secondary outcomes included: proportion of patients with complete response at the end of treatment, reduction in the number of lesions by the Investigator Global Assessment (IGA), improvement in numerical rating scale of sleep (NRSS), improvement in quality of life measured by the Dermatology Life Quality Index (DLQI), time until patient perceived any improvement (Time-First) and time until patient reported absence of pruritus (Time-Final). Descriptive statistics were calculated for each demographic and clinical variable. Univariate logistic regression analyses were conducted to explore association between response to dupilumab and potential predictive factors. We included 25 articles in the analysis, counting a total of 153 patients. Based on CP patients' cohort (n=132), the mean NRSI at baseline was 8.79 ±0.86 and the NRSI final was 2.32 ±1.27. The mean time to first improvement was 5.18 ±3.13 weeks, while the time to complete improvement of pruritus (Time-final) was 13.6 ±12.0 weeks. Ninety patients out of 109 (83%) noticed improvement in pruritus before 4 weeks of dupilumab therapy. At the end of treatment, 18 patients out of 126 (14%) had a complete remission of pruritus and 110 patients out of 123 (89%) had a reduction of NRSI > 4. The reduction in NRSI was significantly greater in patients improving before 4 weeks of treatment (6.57 ±1.71) compared to patients improving in more than 4 weeks (5.49 ±1.39, p<0.001). Patients with history of AD and those who have been previously treated with cyclosporine or methotrexate had a significantly lower reduction in NRSI (e.g. 6.05 ±1.34 vs 7.08 ±1.90 p<0.01 for non-associated AD patients). Based on CIP patient's cohort (n=21), the mean NRSI at baseline was 8.33 ±0.80 and the NRSI final was 0.95 ±0.59. The mean time to first improvement was 2 ±0 weeks, while the time to complete improvement (Time-final) was 14.6 ±10 weeks. At the end of treatment, 3 patients out of 21 (14%) had a complete remission of pruritus and 100% of patients had a reduction of NRSI > 4. No serious treatment-emergent adverse events were reported. The most common adverse event was mild conjunctivitis (13 cases). We highlight the importance of one early sign of improvement as predictor of the future response to dupilumab: the improvement before 4 weeks of treatment that leads significantly to a greater final reduction in NRSI. Furthermore, patients with the presence or history of atopy appear to be less responsive to dupilumab than non-atopic patients and develop more side effects, in particular conjunctivitis.
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Affiliation(s)
- M Gael
- Department of Dermatology, CHRU de Nancy, 6 rue du Morvan, 54500 Vandœuvre lès, Nancy, France
| | - T Adam
- Department of Allergology, CHRU de Nancy, 6 rue du Morvan, 54500 Vandœuvre lès, Nancy, France
| | - M Mariano-Bourin
- Department of Dermatology, CHRU de Nancy, 6 rue du Morvan, 54500 Vandœuvre lès, Nancy, France
| | - A C Bursztejn
- Department of Dermatology, CHRU de Nancy, 6 rue du Morvan, 54500 Vandœuvre lès, Nancy, France
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Singh S, Behl T, Sharma N, Zahoor I, Chigurupati S, Yadav S, Rachamalla M, Sehgal A, Naved T, Arora S, Bhatia S, Al-Harrasi A, Mohan S, Aleya L, Bungau S. Targeting therapeutic approaches and highlighting the potential role of nanotechnology in atopic dermatitis. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2022; 29:32605-32630. [PMID: 35195869 DOI: 10.1007/s11356-021-18429-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/27/2021] [Indexed: 06/14/2023]
Abstract
Atopic dermatitis is a chronic as well as widespread skin disease which has significant influence on the life attributes of affected people and their families. Systemic immunosuppressive drugs can be utilised for effective care of disease, although they are often prescribed for rigorous disruption or disease that is complicated to manage. Therefore, topical applications of corticosteroids are considered the primary pharmacologic therapies for atopic dermatitis, and research recommends that these medications might be helpful in preventing disease flare-ups. However, topical medicine administration to deeper layers of skin is challenging because of the skin anatomic barrier that restricts deeper drug permeation, and also due to barrier function abnormalities in atopic dermatitis skin, which might result in systemic drug absorption, provoking systemic consequences. Hence, effective management of atopic dermatitis needs new, effective, safe and targeted treatments. Therefore, nanotechnology-based topical therapeutics have attracted much interest nowadays because of their tendency to increase drug diffusion and bioavailability along with enormous drug targeting potential to affected cells, and, thereby, reducing the adverse effects of medications. In this review, we mention different symptoms of atopic dermatitis, and provide an overview of the different triggering factors causing atopic dermatitis, with emphasis on its epidemiology, pathophysiology, clinical features and diagnostic, and preventive measures. This review discusses existing therapeutics for treating atopic dermatitis, and the newer approaches as well as the current classical pharmacotherapy of atopic dermatitis against new nanoparticle skin delivery systems. This review has also briefly summarised the recent patents and clinical status of therapeutic modalities for atopic dermatitis.
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Affiliation(s)
- Sukhbir Singh
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Tapan Behl
- Chitkara College of Pharmacy, Chitkara University, Punjab, India.
| | - Neelam Sharma
- Chitkara College of Pharmacy, Chitkara University, Punjab, India.
| | - Ishrat Zahoor
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Sridevi Chigurupati
- Department of Medicine Chemistry and Pharmacognosy, Qassim University, Buraidah, Kingdom of Saudi Arabia
| | - Shivam Yadav
- Yashraj Institute of Pharmacy, Noida, Uttar Pradesh, India
| | - Mahesh Rachamalla
- Department of Biology, University of Saskatchewan, 112 Science Place, Saskatoon, Canada
| | - Aayush Sehgal
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Tanveer Naved
- Amity Institute of Pharmacy, Amity University, Noida, Uttar Pradesh, India
| | - Sandeep Arora
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Saurabh Bhatia
- Natural & Medical Sciences Research Center, University of Nizwa, Nizwa, Oman
- School of Health Science, University of Petroleum and Energy Studies, Dehradun, Uttarakhand, India
| | - Ahmed Al-Harrasi
- Natural & Medical Sciences Research Center, University of Nizwa, Nizwa, Oman
| | - Syam Mohan
- Substance Abuse and Toxicology Research Center, Jazan University, Jazan, Saudi Arabia
| | - Lotfi Aleya
- School of Health Science, University of Petroleum and Energy Studies, Dehradun, Uttarakhand, India
| | - Simona Bungau
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea, Romania
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Kabashima K, Irie H. Interleukin-31 as a Clinical Target for Pruritus Treatment. Front Med (Lausanne) 2021; 8:638325. [PMID: 33644103 PMCID: PMC7906974 DOI: 10.3389/fmed.2021.638325] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 01/14/2021] [Indexed: 12/22/2022] Open
Abstract
In recent years, the published literature has suggested the key involvement of the cytokine interleukin-31 (IL-31) in the symptomatology of pruritus, and both IL-31 and its receptor have become potential therapeutic targets for a range of pruritic diseases. Elevated levels of IL-31 or its receptor have been reported in the tissue or serum of patients with pruritic skin diseases, such as atopic dermatitis, prurigo nodularis, and psoriasis. Pruritus places a heavy burden on patients, and can have a negative impact on daily life, sleep, and mental health. Since current anti-pruritic treatments are often ineffective, affected patients are in urgent need of new therapies. As a result, drug development targeting the IL-31 pathway is evolving rapidly. To date, only nemolizumab, a humanized monoclonal antibody targeting the IL-31 receptor, has successfully completed late-stage clinical studies. This article will highlight our current clinical understanding of the role of IL-31 in pruritic disease, and explore recent progress in drug development as well as the anticipated future advances in this field.
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Affiliation(s)
- Kenji Kabashima
- Department of Dermatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroyuki Irie
- Department of Dermatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Kahremany S, Hofmann L, Harari M, Gruzman A, Cohen G. Pruritus in psoriasis and atopic dermatitis: current treatments and new perspectives. Pharmacol Rep 2021; 73:443-453. [PMID: 33460006 DOI: 10.1007/s43440-020-00206-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/11/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023]
Abstract
Psoriasis and atopic dermatitis (AD) are two common chronic inflammatory skin diseases. Although showing different etiology and clinical manifestations, patients with either disease suffer from low health-related quality of life due to pruritus (dermal itch). Recent studies have revealed that more than 85% of psoriasis patients suffer from pruritus, and it is also the dominating symptom of AD. However, as this is a non-life treating symptom, it was partly neglected for years. In this review, we focus on current findings as well as the impact and potential treatments of pruritus in these two skin diseases. We first distinguish the type of itch based on involved mediators and modulators. This clear delineation between the types of pruritus based on involved receptors and pathways allows for precise treatment. In addition, insights into recent clinical trials aimed to alleviate pruritus by targeting these receptors are presented. We also report about novel advances in combinatorial treatments, dedicated to the type of pruritus linked to a causal disease. Altogether, we suggest that only a focused treatment tailored to the primary disease and the underlying molecular signals will provide fast and sustained relief of pruritus associated with psoriasis or AD.
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Affiliation(s)
- Shirin Kahremany
- Department of Chemistry, Faculty of Exact Sciences, Bar-Ilan University, 5290002, Ramat Gan, Israel. .,The Skin Research Institute, The Dead Sea and Arava Science Center, 86910, Masada, Israel.
| | - Lukas Hofmann
- Department of Chemistry, Faculty of Exact Sciences, Bar-Ilan University, 5290002, Ramat Gan, Israel
| | - Marco Harari
- Medical Climatotherapy Unit, The Dead Sea and Arava Science Center, 86910, Masada, Israel
| | - Arie Gruzman
- Department of Chemistry, Faculty of Exact Sciences, Bar-Ilan University, 5290002, Ramat Gan, Israel
| | - Guy Cohen
- The Skin Research Institute, The Dead Sea and Arava Science Center, 86910, Masada, Israel.,Ben Gurion University of the Negev, Eilat Campus, 8855630, Eilat, Israel
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Molkara S, Sabourirad S, Molooghi K. Infectious differential diagnosis of chronic generalized pruritus without primary cutaneous lesions: a review of the literature. Int J Dermatol 2020; 59:30-36. [PMID: 31364165 DOI: 10.1111/ijd.14587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 06/03/2019] [Accepted: 06/19/2019] [Indexed: 01/24/2023]
Abstract
Pruritus is one of the most common complaints among patients referred to a dermatology clinic. "Chronic generalized pruritus" is described as the sensation of itching on the entire body surface, which lasts at least 6 or more weeks. This symptom can be a disabling phenomenon for patients and may sometimes interfere with daily activities such as sleep. If specific dermatological findings are observed, the physician easily comes to a diagnosis and treats the condition, whereas, when primary lesions are not detected, the diagnosis can become challenging, and some patients have to undergo extensive evaluations. The association between some systemic disorders and chronic generalized pruritus is widely known and confirmed. Many infections have been associated with pruritus, but few are considered to cause chronic generalized pruritus without any characteristic skin lesions. We aimed to gather all the available data on infectious causes of chronic generalized pruritus with no diagnostic cutaneous lesions to assist fellow physicians in the process of evaluation of these challenging cases.
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Affiliation(s)
- Sara Molkara
- Cutaneous Leishmaniasis Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sara Sabourirad
- Cutaneous Leishmaniasis Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Kasra Molooghi
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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