Oral zinc sulphate in the treatment of acute cutaneous leishmaniasis

In vitro evaluation of herbal based Lesh Nat B cream against Leishmania tropica

Pentavalent antimonials continue to be the standard treatment for cutaneous leishmaniasis. But their use is retarded owing to highly-priced, prolonged hospitalization, noxious and poor solubility. Therefore, there is a dire need to characterize new potential compounds possessing anti-leishmanial activity. Topical therapies that are more successful are an essential alternative therapeutic option for the localized self-limiting form of this disease. We tested the herbal-based topical cream Lesh Nat B against Leishmania tropica KWH23 promastigotes and axenic amastigotes in vitro. The anti-leishmanial activity of Lesh Nat B cream was evaluated using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) assay against promastigotes and axenic amastigotes. The results of Lesh Nat B cream were concentration and incubation time-dependent. After 72 h of incubation, Lesh Nat B cream efficiently suppresses the promastigote form of the parasite, followed by 48 h and 24 h. At 72 h, the lowest and highest levels of activity were 37% and 90%. Amastigotes had a minimum activity of 34% and a maximum activity of 78.5%, respectively. This formulation was more cytotoxic against promastigote form than amastigotes form at 72 h incubation periods. All the experiments were carried out in triplicates. Half-maximal inhibitory concentration (IC50) values were determined to be (66 ug/ml) and (70 ug/ml) against promastigote and amastigote forms, respectively. Moreover, 1.63% hemolytic activity was observed in Lesh Nat B cream at (10 µg/ml) while 3% hemolytic activity was observed at (37 µg/ml). It can be concluded that Lesh Nat B cream demonstrated effective Leishmanicidal and less hemolytic activity and can be used as an alternative therapeutic option for the treatment of cutaneous leishmaniasis; however, more studies are expected to justify its effectiveness in treating cutaneous leishmaniasis in both humans and animals.

The Possible Role of Selected Vitamins and Minerals in the Therapeutic Outcomes of Leishmaniasis

Leishmaniasis is a protozoal disease declared as an endemic in areas suffering from severe malnutrition and poverty. The factors associated with poverty like low income, ecological factors, and malnutrition cause disruption in immunity and host defense increasing risk of infection. Altered resistance to infection and host susceptibility are associated with low micronutrient levels in undernourished patients. Malnutrition has been recognized as a poor predictive marker for leishmaniasis, in particular the deficiency of trace elements like zinc, iron, and vitamin A, B, C, D which has a prominent function in the regulation of innate and adaptive immunity, cell proliferation, human physiology, etc. Malnourishment can exacerbate host sensitivity and pathophysiologic intensity to infection in variety of ways, whereas infection can enhance underlying poor nutrition or enhance host vulnerability and sandfly's urge to attack specific hosts. The intensity of leishmaniasis can be influenced by body mass and micronutrient availability in the blood. Vitamin D, C, zinc, and iron are proved effective in inhibiting the growth of leishmaniasis in both amastigote or promastigote forms, either directly or by acting as precursor for a pathway which inhibits the parasite growth. This article elucidates a new perception to the crucial role of micronutrients and their probable role in the therapeutic outcomes of leishmaniasis. Since there is requirement of novel drugs to fight drug resistance and relapse of leishmaniasis, this article may pave way to understand the importance of micronutrients and their role in therapeutic outcomes of leishmaniasis.

Zinc and Zinc Transporters in Dermatology

Zinc is an important trace mineral in the human body and a daily intake of zinc is required to maintain a healthy status. Over the past decades, zinc has been used in formulating topical and systemic therapies for various skin disorders owing to its wound healing and antimicrobial properties. Zinc transporters play a major role in maintaining the integrity of the integumentary system by controlling zinc homeostasis within dermal layers. Mutations and abnormal function of zinc-transporting proteins can lead to disease development, such as spondylocheirodysplastic Ehlers-Danlos syndrome (SCD-EDS) and acrodermatitis enteropathica (AE) which can be fatal if left untreated. This review discusses the layers of the skin, the importance of zinc and zinc transporters in each layer, and the various skin disorders caused by zinc deficiency, in addition to zinc-containing compounds used for treating different skin disorders and skin protection.

Zinc in Human Health and Infectious Diseases

During the last few decades, the micronutrient zinc has proven to be an important metal ion for a well-functioning immune system, and thus also for a suitable immune defense. Nowadays, it is known that the main cause of zinc deficiency is malnutrition. In particular, vulnerable populations, such as the elderly in Western countries and children in developing countries, are often affected. However, sufficient zinc intake and homeostasis is essential for a healthy life, as it is known that zinc deficiency is associated with a multitude of immune disorders such as metabolic and chronic diseases, as well as infectious diseases such as respiratory infections, malaria, HIV, or tuberculosis. Moreover, the modulation of the proinflammatory immune response and oxidative stress is well described. The anti-inflammatory and antioxidant properties of zinc have been known for a long time, but are not comprehensively researched and understood yet. Therefore, this review highlights the current molecular mechanisms underlying the development of a pro-/ and anti-inflammatory immune response as a result of zinc deficiency and zinc supplementation. Additionally, we emphasize the potential of zinc as a preventive and therapeutic agent, alone or in combination with other strategies, that could ameliorate infectious diseases.

Leishmaniasis and Trace Element Alterations: a Systematic Review

Leishmaniasis is a worldwide prevalent parasitic infection caused by different species of the genus Leishmania. Clinically, the disease divided into three main forms, including visceral leishmaniasis (VL), cutaneous leishmaniasis (CL), and mucocutaneous leishmaniasis (MCL). There is no vaccine for human leishmaniasis and their treatment is challenging. Trace elements (TEs) alteration, including the selenium (Se), zinc (Zn), copper (Cu), ron (Fe), and magnesium (Mg) have been detected in patients with CL and VL as well as canine leishmaniasis. Because TEs play a pivotal role in the immune system, and host immune responses have crucial roles in defense against leishmaniasis, this systematic review aimed to summarize data regarding TEs alteration in human and animal leishmaniasis as well as the role of these elements as an adjuvant for treatment of leishmaniasis. In a setting of systematic review, we found 29 eligible articles (any date until October 1, 2020) regarding TEs in human CL (N = 12), human VL (N = 4), canine leishmaniasis (N = 3), and treatment of leishmaniasis based on TEs (N = 11), which one study examined the TEs level both in CL and VL patients. Our analysis demonstrated a significantly decreased level of Fe, Zn, and Se among human CL and canine leishmaniasis, and Zn and Fe in patients with VL. In contrast, an increased level of Cu in CL patients and Cu and Mg in VL patients and canine leishmaniasis was observed. Treatment of CL based zinc supplementation revealed enhancement of wound healing and diminished scar formation in human and experimentally infected animals. The results of this systematic review indicate that the TEs have important roles in leishmaniasis, which could be assessed as a prognosis factor in this disease. It is suggested that TEs could be prescribed as an adjuvant for the treatment of CL and VL patients.

Using Q-methodology to understand the perspectives and practical experiences of dermatologists about treatment difficulties of cutaneous leishmaniasis

Background

During the outbreak of cutaneous leishmaniasis in the Kurdistan Region of Iraq that started in 2015, the course of the disease and the treatment were not consistent with the available literature. Physicians, particularly dermatologists, faced challenges with treating the cutaneous leishmaniasis lesions with high rates of treatment failure and resistance to treatment. We used Q-methodology to understand the range and diversities of opinions and the practical experiences of dermatologists about the treatment difficulties of cutaneous leishmaniasis.

Methods

This Q-methodology study was carried out in Erbil, Kurdistan Region of Iraq, and involved 37 dermatologists. A set of 40 statements related to different aspects of difficulties and uncertainties of treating cutaneous leishmaniasis was prepared. The dermatologists were requested to distribute the 40 statements into a scaled grid of nine piles from least agree to most agree. We applied by-person factor analysis using PQMethod 2.35 for the data analysis.

Results

The analysis revealed two different viewpoints about the treatment of cutaneous leishmaniasis and a consensus viewpoint. The first viewpoint emphasized the use of sodium stibogluconate-based combination therapy, concerns with treatment failure, and lack of compliance with the treatment. The second viewpoint emphasized the lack of standard treatment and advances in the treatment of cutaneous leishmaniasis. There was a consensus between both groups of respondents about many aspects of the treatment of cutaneous leishmaniasis, including considering sodium stibogluconate the first drug of choice for cutaneous leishmaniasis treatment.

Conclusions

This study revealed a diversity of viewpoints and uncertainties about the effectiveness of the available treatment modalities and treatment difficulties and failure. Interrupted supply and poor quality of the available drugs and lack of a standard and advanced treatment are the main problems facing the treatment of cutaneous leishmaniasis. More research is required to determine the best treatment modalities for the different types of cutaneous leishmaniasis. There is a need for the development of treatment guidelines specific to the Iraqi context with a particular focus on the treatment of the resistant and atypical cases of cutaneous leishmaniasis.

Parasite Sensing of Host Nutrients and Environmental Cues

Parasites undergo complex life cycles that comprise a wide variety of cellular differentiation events in different host compartments and transmission across multiple hosts. As parasites depend on host resources, it is not surprising they have developed efficient mechanisms to sense alterations and adapt to the available resources in a wide range of environments. Here we provide an overview of the nutritional needs of different parasites throughout their diverse life stages and highlight recent insights into strategies that both hosts and parasites have developed to meet these nutritional requirements needed for defense, survival, and replication. These studies will provide the foundation for a systems-level understanding of host-parasite interactions, which will require the integration of molecular, epidemiologic, and mechanistic data and the application of interdisciplinary approaches to model parasite regulatory networks that are triggered by alterations in host resources.

Polyethylene glycol-coated zinc oxide nanoparticle: an efficient nanoweapon to fight against herpes simplex virus type 1

AIM

We aimed to determine the possible inhibitory effects of zinc oxide nanoparticles (ZnO-NPs) and polyethylene glycol (PEG)-coated ZnO-NPs (ZnO-PEG-NPs) on herpes simplex virus type 1 (HSV-1).

MATERIALS & METHODS

PEGylated ZnO-NPs were synthesized by the mechanical method. Antiviral activity was assessed by 50% tissue culture infectious dose (TCID₅₀) and real-time PCR assays. To confirm the antiviral activity of ZnO-NPs on expression of HSV-1 antigens, indirect immunofluorescence assay was also conducted.

RESULTS

200 μg/ml ZnO-PEG-NPs could result in 2.5 log₁₀ TCID₅₀ reduction in virus titer, with inhibition rate of approximately 92% in copy number of HSV-1 genomic DNA.

CONCLUSION

ZnO-PEG-NPs could be proposed as a new agent for efficient HSV-1 inhibition. Our results indicated that PEGylation is effective in reducing cytotoxicity and increasing antiviral activity of nanoparticles.

Evaluation of the efficacy of intralesional Glucantime plus niosomal zinc sulphate in comparison with intralesional Glucantime plus cryotherapy in the treatment of acute cutaneous leishmaniasis, a randomized clinical trial

Current treatment modalities in cutaneous leishmaniasis have low efficacy and high toxicity as well as high rate of resistance to treatment. In this study, for the first time we decided to evaluate efficacy of intralesional Glucantime plus niosomal zinc sulphate in comparison with intralesional Glucantime plus cryotherapy in the treatment of acute cutaneous leishmaniasis. This is a case-control study on 64 patients with cutaneous leishmaniasis in Kerman-Iran. Patients were categorized in 2 groups A and B whom were treated with weekly intralesional meglumine antimonite plus twice daily niosomal topical zinc sulphate versus weekly intralesional Glucantime plus every other week cryotherapy, respectively. We assessed the efficacy of treatment modalities (as partial and complete response) and their adverse effects by measuring size of the lesions every 2 weeks up to maximum of 12 weeks and 3 months after the end of the treatment. Partial response rate was 16.6% and 12.9% in group A and B, respectively (P = 0.784). Complete response rate was 73.3% and 80.6% in group A and B, respectively (P = 0.784). Complete response rate was achieved in 4.73 ± 0.29 weeks and 4.69 ± 0.28 weeks in group A and B, respectively (P = 0.925). Partial response rate was achieved in 2.92 ± 0.23 weeks and 2.65 ± 0.18 weeks, respectively (P = 0.365). Combination of niosomal zinc sulphate with intralesional Glucantime has equal efficacy versus combination of cryotherapy plus intralesional Glucantime in the treatment of acute cutaneous leishmaniasis. So, it can be used in cases that have resistance to first-line treatments.

Cryotherapy plus oral zinc sulfate versus cryotherapy plus placebo to treat common warts: A double blind, randomized, placebo-controlled trial

BACKGROUND

Cutaneous warts are caused by a small group of specific types of human papillomaviruses. Cryotherapy is a highly effective treatment for patients with viral warts; however, it is a painful method and usually requires several treatment sessions. Zinc is a trace element with many proven effects on the immune system.

OBJECTIVE

Our aim was to assess the efficacy and safety of oral zinc sulfate in the treatment and recurrence rate of common warts.

METHODS

Eighty-three patients with common warts participated in this double-blind, randomized, placebo-controlled trial. In both groups, three sessions of liquid nitrogen cryotherapy were performed for up to 2 months with 3-week intervals. The treatment group (n = 45) received oral zinc sulfate capsules in a dose of 10 mg/kg per day up to 600 mg day. The control group (n = 38) was provided with placebo of similar appearance. Treatment continued for 2 months and the follow-up period lasted up to 6 months.

RESULTS

Warts completely resolved in 26 patients in the treatment group (68.4%) and 23 patients in the placebo group (63.9%; p = .68). Three patients (7.9%) in the treatment group and six patients (16.6%) in the placebo group has a recurrence of the warts (p = .19).

CONCLUSION

According to our study, the addition of zinc to cryotherapy was not beneficial in the treatment of patients with common warts nor did it prevent recurrences.

Eligibility criteria and outcome measures adopted in clinical trials of treatments of cutaneous leishmaniasis: systematic literature review covering the period 1991-2015

OBJECTIVE

To document the sources of heterogeneity in outcomes and shortcomings in trial designs reported by previous systematic reviews.

METHODS

Systematic review of clinical trials of CL treatments published since 1991, to assess and compare eligibility criteria and outcome measures in trials (any type of treatment) of CL (any form) reported before and after the publication of the CONSORT statement.

RESULTS

We identified 106 eligible trials published between 1991 and 2015, 74% after the 2001 CONSORT statement; 58% (n = 63) were on Old-World CL and 37% (n = 40) in New-World CL; overall, 11 531 patients enrolled in 243 treatment groups on 30 different treatments. Both requirements and definitions for eligibility and outcome criteria varied. Compliance with CONSORT requirements increased for studies published after the 2010 update. As for entry criteria, 94% of studies had a requirement for sex (74% of those enrolling also women excluded those who were pregnant or lactating), 69% for age (variable age ranges), 99% parasitological confirmation, 43% prior duration of illness (14% excluded cases with previous episodes), 46% defined the number, 28% the size and 13% the type of lesions (27% with restrictions as to their anatomical location). Follow-up ranged 1-24 months, with 14% and 91% of studies, respectively, having defined initial and final cure.

CONCLUSIONS

This review documents changes in reporting before and after the publication of the CONSORT statement. Lack of standardisation, compounded with the small number of trials relative to the magnitude of the disease in its multiple forms, and with the range of treatments tested explains why evidence to inform treatment guidelines is generally weak for CL. Adopting standardised methodologies will improve the quality and consistency of clinical trials, and ultimately yield better treatments for CL.

Interventions for Old World cutaneous leishmaniasis

BACKGROUND

Cutaneous leishmaniasis, caused by a parasitic infection, is considered one of the most serious skin diseases in many low- and middle-income countries. Old World cutaneous leishmaniasis (OWCL) is caused by species found in Africa, Asia, the Middle East, the Mediterranean, and India. The most commonly prescribed treatments are antimonials, but other drugs have been used with varying success. As OWCL tends to heal spontaneously, it is necessary to justify the use of systemic and topical treatments. This is an update of a Cochrane Review first published in 2008.

OBJECTIVES

To assess the effects of therapeutic interventions for the localised form of Old World cutaneous leishmaniasis.

SEARCH METHODS

We updated our searches of the following databases to November 2016: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). We wrote to national programme managers, general co-ordinators, directors, clinicians, WHO-EMRO regional officers of endemic countries, pharmaceutical companies, tropical medicine centres, and authors of relevant papers for further information about relevant unpublished and ongoing trials. We undertook a separate search for adverse effects of interventions for Old World cutaneous leishmaniasis in September 2015 using MEDLINE.

SELECTION CRITERIA

Randomised controlled trials of either single or combination treatments in immunocompetent people with OWCL confirmed by smear, histology, culture, or polymerase chain reaction. The comparators were either no treatment, placebo/vehicle, and/or another active compound.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias and extracted data. We only synthesised data when we were able to identify at least two studies investigating similar treatments and reporting data amenable to pooling. We also recorded data about adverse effects from the corresponding search.

MAIN RESULTS

We included 89 studies (of which 40 were new to this update) in 10,583 people with OWCL. The studies included were conducted mainly in the Far or Middle East at regional hospitals, local healthcare clinics, and skin disease research centres. Women accounted for 41.5% of the participants (range: 23% to 80%). The overall mean age of participants was 25 years (range 12 to 56). Most studies lasted between two to six months, with the longest lasting two years; average duration was four months. Most studies were at unclear or high risk for most bias domains. A lack of blinding and reporting bias were present in almost 40% of studies. Two trials were at low risk of bias for all domains. Trials reported the causative species poorly.Here we provide results for the two main comparisons identified: itraconazole (200 mg for six to eight weeks) versus placebo; and paromomycin ointment (15% plus 10% urea, twice daily for 14 days) versus vehicle.In the comparison of oral itraconazole versus placebo, at 2.5 months' follow up, 85/125 participants in the itraconazole group achieved complete cure compared to 54/119 in the placebo group (RR 3.70, 95% CI 0.35 to 38.99; 3 studies; 244 participants). In one study, microbiological or histopathological cure of skin lesions only occurred in the itraconazole group after a mean follow-up of 2.5 months (RR 17.00, 95% CI 0.47 to 612.21; 20 participants). However, although the analyses favour oral itraconazole for these outcomes, we cannot be confident in the results due to the very low certainty evidence. More side effects of mild abdominal pain and nausea (RR 2.36, 95% CI 0.74 to 7.47; 3 studies; 204 participants) and mild abnormal liver function (RR 3.08, 95% CI 0.53 to 17.98; 3 studies; 84 participants) occurred in the itraconazole group (as well as reports of headaches and dizziness), compared with the placebo group, but again we rated the certainty of evidence as very low so are unsure of the results.When comparing paromomycin with vehicle, there was no difference in the number of participants who achieved complete cure (RR of 1.00, 95% CI 0.86, 1.17; 383 participants, 2 studies) and microbiological or histopathological cure of skin lesions after a mean follow-up of 2.5 months (RR 1.03, CI 0.88 to 1.20; 383 participants, 2 studies), but the paromomycin group had more skin/local reactions (such as inflammation, vesiculation, pain, redness, or itch) (RR 1.42, 95% CI 0.67 to 3.01; 4 studies; 713 participants). For all of these outcomes, the certainty of evidence was very low, meaning we are unsure about these results.Trial authors did not report the percentage of lesions cured after the end of treatment or speed of healing for either of these key comparisons.

AUTHORS' CONCLUSIONS

There was very low-certainty evidence to support the effectiveness of itraconazole and paromomycin ointment for OWCL in terms of cure (i.e. microbiological or histopathological cure and percentage of participants completely cured). Both of these interventions incited more adverse effects, which were mild in nature, than their comparisons, but we could draw no conclusions regarding safety due to the very low certainty of the evidence for this outcome.We downgraded the key outcomes in these two comparisons due to high risk of bias, inconsistency between the results, and imprecision. There is a need for large, well-designed international studies that evaluate long-term effects of current therapies and enable a reliable conclusion about treatments. Future trials should specify the species of leishmaniasis; trials on types caused by Leishmania infantum, L aethiopica, andL donovani are lacking. Research into the effects of treating women of childbearing age, children, people with comorbid conditions, and those who are immunocompromised would also be helpful.It was difficult to evaluate the overall efficacy of any of the numerous treatments due to the variable treatment regimens examined and because RCTs evaluated different Leishmania species and took place in different geographical areas. Some outcomes we looked for but did not find were degree of functional and aesthetic impairment, change in ability to detect Leishmania, quality of life, and emergence of resistance. There were only limited data on prevention of scarring.

Interventions for Old World cutaneous leishmaniasis

BACKGROUND

Cutaneous leishmaniasis, caused by a parasitic infection, is considered one of the most serious skin diseases in many low- and middle-income countries. Old World cutaneous leishmaniasis (OWCL) is caused by species found in Africa, Asia, the Middle East, the Mediterranean, and India. The most commonly prescribed treatments are antimonials, but other drugs have been used with varying success. As OWCL tends to heal spontaneously, it is necessary to justify the use of systemic and topical treatments. This is an update of a Cochrane Review first published in 2008.

OBJECTIVES

To assess the effects of therapeutic interventions for the localised form of Old World cutaneous leishmaniasis.

SEARCH METHODS

We updated our searches of the following databases to November 2016: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). We wrote to national programme managers, general co-ordinators, directors, clinicians, WHO-EMRO regional officers of endemic countries, pharmaceutical companies, tropical medicine centres, and authors of relevant papers for further information about relevant unpublished and ongoing trials. We undertook a separate search for adverse effects of interventions for Old World cutaneous leishmaniasis in September 2015 using MEDLINE.

SELECTION CRITERIA

Randomised controlled trials of either single or combination treatments in immunocompetent people with OWCL confirmed by smear, histology, culture, or polymerase chain reaction. The comparators were either no treatment, placebo/vehicle, and/or another active compound.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias and extracted data. We only synthesised data when we were able to identify at least two studies investigating similar treatments and reporting data amenable to pooling. We also recorded data about adverse effects from the corresponding search.

MAIN RESULTS

We included 89 studies (of which 40 were new to this update) in 10,583 people with OWCL. The studies included were conducted mainly in the Far or Middle East at regional hospitals, local healthcare clinics, and skin disease research centres. Women accounted for 41.5% of the participants (range: 23% to 80%). The overall mean age of participants was 25 years (range 12 to 56). Most studies lasted between two to six months, with the longest lasting two years; average duration was four months. Most studies were at unclear or high risk for most bias domains. A lack of blinding and reporting bias were present in almost 40% of studies. Two trials were at low risk of bias for all domains. Trials reported the causative species poorly.Here we provide results for the two main comparisons identified: itraconazole (200 mg for six to eight weeks) versus placebo; and paromomycin ointment (15% plus 10% urea, twice daily for 14 days) versus vehicle.In the comparison of oral itraconazole versus placebo, at 2.5 months' follow up, 85/125 participants in the itraconazole group achieved complete cure compared to 54/119 in the placebo group (RR 3.70, 95% CI 0.35 to 38.99; 3 studies; 244 participants). In one study, microbiological or histopathological cure of skin lesions only occurred in the itraconazole group after a mean follow-up of 2.5 months (RR 17.00, 95% CI 0.47 to 612.21; 20 participants). However, although the analyses favour oral itraconazole for these outcomes, we cannot be confident in the results due to the very low certainty evidence. More side effects of mild abdominal pain and nausea (RR 2.36, 95% CI 0.74 to 7.47; 3 studies; 204 participants) and mild abnormal liver function (RR 3.08, 95% CI 0.53 to 17.98; 3 studies; 84 participants) occurred in the itraconazole group (as well as reports of headaches and dizziness), compared with the placebo group, but again we rated the certainty of evidence as very low so are unsure of the results.When comparing paromomycin with vehicle, there was no difference in the number of participants who achieved complete cure (RR of 1.00, 95% CI 0.86, 1.17; 383 participants, 2 studies) and microbiological or histopathological cure of skin lesions after a mean follow-up of 2.5 months (RR 1.03, CI 0.88 to 1.20; 383 participants, 2 studies), but the paromomycin group had more skin/local reactions (such as inflammation, vesiculation, pain, redness, or itch) (RR 1.42, 95% CI 0.67 to 3.01; 4 studies; 713 participants). For all of these outcomes, the certainty of evidence was very low, meaning we are unsure about these results.Trial authors did not report the percentage of lesions cured after the end of treatment or speed of healing for either of these key comparisons.

AUTHORS' CONCLUSIONS

There was very low-certainty evidence to support the effectiveness of itraconazole and paromomycin ointment for OWCL in terms of cure (i.e. microbiological or histopathological cure and percentage of participants completely cured). Both of these interventions incited more adverse effects, which were mild in nature, than their comparisons, but we could draw no conclusions regarding safety due to the very low certainty of the evidence for this outcome.We downgraded the key outcomes in these two comparisons due to high risk of bias, inconsistency between the results, and imprecision. There is a need for large, well-designed international studies that evaluate long-term effects of current therapies and enable a reliable conclusion about treatments. Future trials should specify the species of leishmaniasis; trials on types caused by Leishmania infantum, L aethiopica, andL donovani are lacking. Research into the effects of treating women of childbearing age, children, people with comorbid conditions, and those who are immunocompromised would also be helpful.It was difficult to evaluate the overall efficacy of any of the numerous treatments due to the variable treatment regimens examined and because RCTs evaluated different Leishmania species and took place in different geographical areas. Some outcomes we looked for but did not find were degree of functional and aesthetic impairment, change in ability to detect Leishmania, quality of life, and emergence of resistance. There were only limited data on prevention of scarring.

Comparison between intralesional injection of zinc sulfate 2 % solution and intralesional meglumine antimoniate in the treatment of acute old world dry type cutaneous leishmaniasis: a randomized double-blind clinical trial

Zinc sulfate (ZS) has been used for the treatment of acute cutaneous leishmaniasis (CL) in both forms of in vivo and in vitro recently. The aim of the present study was to compare the efficacy of intralesional injection of ZS 2 % solution with intralesional glucantime in the treatment of acute CL. In this double-blind randomized clinical trial, 80 cases with acute old world dry type CL were enrolled in the study. The treatment protocol in the first group consisted of intralesional injection of ZS 2 % vials once a week for 10 weeks or sooner in case of complete resolution of the lesions. In the second group, intralesional glucantime once a week for 10 weeks or sooner in case of complete resolution of the lesions were used. In both groups cryotherapy was performed once every other week for 10 weeks. In ZS versus second group, partial and complete clinical response was observed with fewer injections although this difference was not statistically significant. In addition, we found that the trend of treatment in second group was faster but again it was not significant [partial treatment: hazard ratio (HR) 1.4, 95 % CI 0.7-2.9; complete treatment: HR 1.3, 95 % CI 0.6-2.8]. The results of this study showed that the intralesional injection of ZS 2 % solution was as effective as glucantime on the healing of the acute old world dry type CL.

Clinical Response with intralesional Amphotericin B in the treatment of old world cutaneous leishmaniasis: a preliminary report

Cutaneous leishmaniasis (CL) is a vector-borne tropical disease caused by a heterogeneous group of protozoan parasites that belong to the genus Leishmania. With an annual incidence of 1.5 million new cases, CL is a global health concern mainly in developing countries. The treatment options for CL are numerous but none is optimal. Pentavalent antimonials despite their side effects remain the preferred choice since decades. Alternate new treatment options are being explored to expand the therapeutic armamentarium of CL. In this study, we intend to describe our therapeutic experience with intralesional amphotericin B in the treatment of CL in a series of Indian patients, hitherto not commonly used in old world CL (OWCL). We also endeavour to review the literature on the use of amphotericin B in OWCL. Five consecutive patients diagnosed with cutaneous leishmansis at the out-patient department of Dermatology, Government Medical College, Jammu were treated with weekly injections of intralesional amphotericin B (2.5 mg/mL). Treatment response was assessed at each visit and the cases were followed up for 6 months. All the five patients responded well to the treatment and remained recurrence-free during follow-up. Intralesional amphotericin B was found to be safe and effective treatment for OWCL. Large randomized control trials need to be conducted to establish its efficacy.

The Clinical Effectiveness of Intralesional Injection of 2% Zinc Sulfate Solution in the Treatment of Common Warts

Objective. To investigate the clinical efficacy and safety of intralesional injection of 2% zinc sulfate solution in the treatment of common warts. Patients and Methods. One hundred and twenty patients (78 females and 42 males) aged 5-55 years with 225 common warts participated in this prospective monocentric randomized study. All lesions were treated with intralesional injection of 2% zinc sulfate. Results. From 225 warts injected, 135 warts (60%) cured from the first session, 51 warts (22.67%) cured from the second session, and 12 warts (5.33%) cured from the third session. There is no significant relation between improvement and patient's ages, duration, or number of warts (P > 0.05). All patients complained from pain during injection, and all treated lesions showed redness, tenderness, and swelling in the first 3 days after injection. Late complications were postinflammatory hyperpigmentation in 90 patients (75%), scaring in 9 patients (7.5%), and ulceration in 3 patients (2.5%). Recurrence occurred in 3 lesions (1.33%). Conclusion. The clinical data indicate that intralesional injection of 2% zinc sulfate is an effective maneuver in the treatment of common warts; however, its associated complications limit its use.

Antileishmanial Activity of Disulfiram and Thiuram Disulfide Analogs in an Ex Vivo Model System Is Selectively Enhanced by the Addition of Divalent Metal Ions

Current treatments for cutaneous and visceral leishmaniasis are toxic, expensive, difficult to administer, and limited in efficacy and availability. Disulfiram has primarily been used to treat alcoholism. More recently, it has shown some efficacy as therapy against protozoan pathogens and certain cancers, suggesting a wide range of biological activities. We used an ex vivo system to screen several thiuram disulfide compounds for antileishmanial activity. We found five compounds (compound identifier [CID] 7188, 5455, 95876, 12892, and 3117 [disulfiram]) with anti-Leishmania activity at nanomolar concentrations. We further evaluated these compounds with the addition of divalent metal salts based on studies that indicated these salts could potentiate the action of disulfiram. In addition, clinical studies suggested that zinc has some efficacy in treating cutaneous leishmaniasis. Several divalent metal salts were evaluated at 1 μM, which is lower than the normal levels of copper and zinc in plasma of healthy individuals. The leishmanicidal activity of disulfiram and CID 7188 were enhanced by several divalent metal salts at 1 μM. The in vitro therapeutic index (IVTI) of disulfiram and CID 7188 increased 12- and 2.3-fold, respectively, against L. major when combined with ZnCl2. The combination of disulfiram with ZnSO4 resulted in a 1.8-fold increase in IVTI against L. donovani. This novel combination of thiuram disulfides and divalent metal ions salts could have application as topical and/or oral therapies for treatment of cutaneous and visceral leishmaniasis.

Immunomodulators in warts: Unexplored or ineffective?

Cutaneous warts are known to be recurrent and often resistant to therapy. Resistant warts may reflect a localized or systemic cell mediated immune (CMI) deficiency to HPV. Many modalities of treatment are in use; most of the provider-administered therapies are destructive and cause scarring, such as cryotherapy, chemical cauterisation, curettage, electrodessication and laser removal. Most patient-applied agents like podophyllotoxin have the risk of application-site reactions and recurrence. Thus immunotherapy is a promising modality which could lead to resolution of warts without any physical changes or scarring and in addition would augment the host response against the causative agent, thereby leading to complete resolution and decreased recurrences. Immunomodulators can be administered systemically, intralesionally or intradermally, and topically. A few agents have been tried and studied extensively such as cimetidine and interferons; others are new on the horizon, such as Echinacea, green tea catechins and quadrivalent HPV vaccine, and their efficacy is yet to be completely established. Though some like levamisole have shown no efficacy as monotherapy and are now used only in combination, other more recent agents require large and long term randomized placebo-controlled trials to clearly establish their efficacy or lack of it. In this review, we focus on the immunomodulators that have been used for the treatment of warts and the studies that have been conducted on them.

Mutual action of anticancer and antiparasitic drugs: are there any shared targets?

ABSTRACT 

Parasites and cancers have some common features. It has been shown that some parasites interfere with tumor growth. In addition, they both have common antigens such as the Tn antigen. A communal action of anticancer and antiparasitic drugs has been reported. This shared action may be related to common targets for these drugs in cancers and parasites. In this paper, mutual action of anticancer and antiparasitic drugs, with the aim of discussing shared targets of these drugs, has been reviewed.

Nutritional status in patients with cutaneous leishmaniasis and a study of the effects of zinc supplementation together with antimony treatment

BACKGROUND

The role of micronutrient status for the incidence and clinical course of cutaneous leishmaniasis is not much studied. Still zinc supplementation in leishmaniasis has shown some effect on the clinical recovery, but the evidence in humans is limited.

OBJECTIVE

To compare biochemical nutritional status in cutaneous leishmaniasis patients with that in controls and to study the effects of zinc supplementation for 60 days.

DESIGN

Twenty-nine patients with cutaneous leishmaniasis were treated with antimony for 20 days. Fourteen of them got 45 mg zinc daily and 15 of them got placebo. Biomarkers of nutritional and inflammatory status and changes in size and characteristics of skin lesions were measured.

RESULTS

The level of transferrin receptor was higher in patients than in controls but otherwise no differences in nutritional status were found between patients and controls. No significant effects of zinc supplementation on the clinical recovery were observed as assessed by lesion area reduction and characteristics or on biochemical parameters.

CONCLUSIONS

It is concluded that nutritional status was essentially unaffected in cutaneous leishmaniasis and that oral zinc supplementation administered together with intramuscular injection of antimony had no additional clinical benefit.

Efficacy of combination therapy of oral zinc sulfate with imiquimod, podophyllin or cryotherapy in the treatment of vulvar warts

AIM

Zinc sulfate is beneficial in the treatment of epithelial warts. We conducted this study to compare the efficacy of combination therapy of oral zinc sulfate with conventional treatments in the treatment of vulvar warts.

MATERIAL AND METHODS

This study was a randomized controlled trial. The sample size was 42 in each group. Women aged 20-50 years were placed by the block randomized method into six groups: the podophyllin-, imiquimod- and cryotherapy-treated groups, and another three groups receiving 8-week combination therapy of 400 mg oral zinc sulfate with one of the above-mentioned treatments. Data were analyzed using anova and Fischer's exact test with spss16.

RESULTS

A total of 228 patients were recruited and completed the study in six treatment groups. No significant difference was observed in the response to treatment among these groups. Relapse after 6 months was significantly higher in the podophyllin-, imiquimod- and cryotherapy-treated patients compared to patients receiving these treatments in combination with oral zinc sulfate (P<0.05).

CONCLUSIONS

Combined therapy of oral zinc sulfate with conventional treatments of vulvar warts appears to reduce the relapse rate.

Zinc therapy in dermatology: a review

Zinc, both in elemental or in its salt forms, has been used as a therapeutic modality for centuries. Topical preparations like zinc oxide, calamine, or zinc pyrithione have been in use as photoprotecting, soothing agents or as active ingredient of antidandruff shampoos. Its use has expanded manifold over the years for a number of dermatological conditions including infections (leishmaniasis, warts), inflammatory dermatoses (acne vulgaris, rosacea), pigmentary disorders (melasma), and neoplasias (basal cell carcinoma). Although the role of oral zinc is well-established in human zinc deficiency syndromes including acrodermatitis enteropathica, it is only in recent years that importance of zinc as a micronutrient essential for infant growth and development has been recognized. The paper reviews various dermatological uses of zinc.

Zinc, its biological role and use in dermatology

This literature review detines the biological role ot zinc in the human body, immune homeostasis and skin physiology as well as pathophysiology ot skin diseases. It describes the current range ot systemic and topical zinc preparations and their pharmacological characteristics. The review also describes skin diseases that may be treated with the use ot zinc preparations on a grounded basis, and discloses the clinical experience ot the use ot these drugs described in the world literature. It sets out certain recommendations tor using zinc preparations in clinical practice.

The mechanism behind the antileishmanial effect of zinc sulphate. II. Effects on the enzymes of the parasites

When used in vitro, zinc sulphate has a direct antileishmanial effect. To see if this effect involved the inhibition of the parasites' enzymes, extracts of the promastigotes and axenic amastigotes of Leishmania major (MHOM/IQ/93/MRC6) and L. tropica (MHOM/IQ/93/MRC2) were prepared. Zinc sulphate, at various concentrations, was then added to samples of these extracts before the activities, in the samples, of certain key enzymes of the Embden-Meyerhof pathway, hexose-monophosphate shunt and citric-acid cycle, and of two enzymes associated with virulence (protease and acid phosphatase), were determined. The zinc was found to inhibit every enzyme investigated, usually in a dose-dependent manner. Thus the direct antileishmanial effect of zinc may result, partially or entirely, from the inhibition of enzymes that are necessary for the parasites' carbohydrate metabolism and virulence.

Panniculitis is an important feature of cutaneous leishmaniasis pathology

Background. Cutaneous leishmaniasis is an inflammatory parasitic infection characterized by superficial and deep perivascular infiltration with or without granuloma formation. Clinical diagnosis usually requires seeing Leishmania bodies. Methods. We report two cases of cutaneous leishmaniasis with unusual histological finding of panniculitis. Case 1: a 36-year-old male presented with multiple ulcerative nodules involving the left leg for two months duration which was greatly responsive to antimony intralesional therapy. Case 2: A 45-year-old woman presented with painless nodules on her upper chest of a 10-week duration which were successfully treated with oral and topical zinc sulphate. Results. Diagnosis of both cases was confirmed by finding the Leishmania bodies with Gimesa stain in addition to the diffuse dermal inflammatory cellular infiltration of the dermis forming granulomatous dermatitis. Mixed cellular infiltration of lymphocytes, histiocytes, and plasma cells of the panniculus caused both septal and lobular panniculitis. Conclusion. Cutaneous leishmaniasis can cause panniculitis and this could be seen more commonly if deep biopsies were taken. So cutaneous leishmaniasis must be considered in evaluating pathology of panniculitis especially in endemic regions.

Comparison of intralesional two percent zinc sulfate and glucantime injection in treatment of acute cutaneous leishmaniasis

Introduction:

Cutaneous leishmaniasis is an endemic disease in developing countries caused by different species of leishmania parasite, and if left untreated, it will result in a deformed scar after a relatively long period. Although various systemic and topical treatments have been proposed for leishmaniasis, pentavalent Antimony compounds remain the first-line treatment for it. Considering the cases with treatment failure, potential side effects and reluctance of patients to receive the drug, there are continuing efforts to find better treatment alternatives.

Aim:

Comparison of the effect of intralesional 2% zinc sulfate injection with Glucantime in treatment of acute cutaneous leishmaniasis.

Materials and Methods:

In this clinical trial, 45 patients with clinical diagnosis of cutaneous leishmaniasis and positive direct smear for leishman body were treated by intralesional injection of either 2% zinc sulfate or Glucantime. After simple randomization, in one group the patients were treated with 2 bouts of intralesional 2% zinc sulfate with a 2-week interval, and in the other group they were treated with 6 weekly bouts of intralesional Glucantime. The patients were monitored in two week intervals for 8 weeks. Healing of the lesions was evaluated clinically and by direct smear, and the data were analyzed using SPSS (11.5) software, t-Student, Mann-Whitney and Analysis of covariance (ANCOVA) statistical tests.

Findings:

In the end of study, 34 patients completed the study, 10 of whom received intralesional Glucantime and 24 of whom received intralesional 2% zinc sulfate. The healing rate after 8 weeks was 80% in the group receiving intralesional Glucantime and 33.3% in the one receiving 2% zinc sulfate (P=0.009).

Conclusion:

Based on the results of this study, intralesional injection of 2% zinc sulfate was less effective in treatment of cutaneous leishmaniasis than intralesional Glucantime.

Hypothesis: zinc can be effective in treatment of vitiligo

Vitiligo is a common depigmenting skin disorder (prevalence 0.1-2%), still represents a cause of stigmatization and quality of life impairment in a large population. Several theories on vitiligo etiopathogenesis have been suggested including in trauma, stress, and autoimmune and genetic predisposition, accumulation of toxic compounds, altered cellular environment, imbalance in the oxidant-antioxidant system, impaired melanocyte migration and/or proliferation, infection, and psychological factors. Zinc, as a trace element, has many vital functions in human. It is antiapoptotic factor and needed as a cofactor for antioxidant defense system. It plays an important role in the process of melanogenesis. It may be effective in prevention and treatment of vitiligo via some mechanism. Herein, we suggested some probable protective mechanism for zinc in association with vitiligo.

Comparison of oral zinc sulfate with systemic meglumine antimoniate in the treatment of cutaneous leishmaniasis

The purpose of this study was to investigate comparison between oral zinc sulfate and meglumine antimoniate in the treatment of cutaneous leishmaniasis (CL). So 100 patients with CL were included and randomly divided into two groups. The first group was treated with oral zinc sulfate (10 mg/kg/day during 45 days period), and the second group was treated with systemic meglumine antimoniate (20 mg/kg/day intramuscularly for 20 days). Acceptable cure after completing 45 days of followup occurred in 30.2% of lesions in first group, while this was 35.5% for the second group. There is not any significant difference between the two treatment groups (P = 0.42). Serious side effects resulting in treatment discounting occurred in only meglumine antimoniate group. Although cure rate of systemic meglumine antimoniate group was better the treatment with zinc sulfate is much easier, cheaper, more convenient in consumption, safer, and nearly close cure percentage to systemic meglumine antimoniate injections without serious side effect.

Innovative uses for zinc in dermatology

Severe zinc deficiency states, such as acrodermatitis enteropathica, are associated with a variety of skin manifestations, such as perioral, acral, and perineal dermatitis. These syndromes can be reversed with systemic zinc repletion. In addition to skin pathologies that are clearly zinc-dependent, many dermatologic conditions (eg, dandruff, acne, and diaper rash) have been associated and treated with zinc. Success rates for treatment with zinc vary greatly depending on the disease, mode of administration, and precise zinc preparation used. With the exception of systemic zinc deficiency states, there is little evidence that convincingly demonstrates the efficacy of zinc as a reliable first-line treatment for most dermatologic conditions. However, zinc may be considered as an adjunctive treatment modality. Further research is needed to establish the indications for zinc treatment in dermatology, optimal mode of zinc delivery, and best type of zinc compound to be used.

Interventions for Old World cutaneous leishmaniasis

BACKGROUND

Cutaneous leishmaniasis is caused by a parasitic infection and is considered one of the most serious skin diseases in many developing countries. Antimonials are the most commonly prescribed treatment but other drugs have been used with varying success.

OBJECTIVES

To assess the effects of treatments for Old World cutaneous leishmaniasis (OWCL).

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (April 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2008), MEDLINE (2003-April 2008), EMBASE (2005-April 2008), CINAHL (1982-August 2007), LILACS (from inception to April 2008) and ongoing trials databases (August 2007).

SELECTION CRITERIA

Randomised controlled trials assessing treatments in immuno-competent people with OWCL confirmed by smear, histology, culture or polymerase chain reaction.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data.

MAIN RESULTS

We included 49 trials involving 5559 participants. Reporting quality was generally poor and only two studies contained sufficiently similar data to pool.In Leishmania major infections, there was good RCT evidence of benefit of cure around 3 months after treatment when compared to placebo for 200 mg oral fluconazole (1 RCT n = 200, RR 2.78; 95% CI 1.86, 4.16), topical 15% paromomycin + 12% methylbenzethonium chloride (PR-MBCL) (1 RCT n = 60, RR 3.09; 95% CI 1.14, 8.37) and photodynamic therapy (1 RCT n = 60, RR 7.02; 95% CI 3.80, 17.55). Topical PR-MBCL was less efficacious than photodynamic therapy (1 RCT n = 65, RR 0.44; 95% CI 0.29, 0.66). Oral pentoxifylline was a good adjuvant therapy to intramuscular meglumine antimoniate (IMMA) when compared to IMMA plus placebo (1 RCT n = 64, RR 1.63; 95% CI 1.11, 2.39)In Leishmania tropica infections, there was good evidence of benefit for the use of 200 mg oral itraconazole for 6 weeks compared with placebo (1 RCT n = 20, RR 7.00; 95% CI 1.04, 46.95), for intralesional sodium stibogluconate (1 RCT n = 292, RR 2.62; 95% CI 1.78, 3.86), and for thermotherapy compared with intramuscular sodium stibogluconate (1 RCT n = 283, RR 2.99; 95% CI 2.04, 4.37).

AUTHORS' CONCLUSIONS

Most trials have been designed and reported poorly, resulting in a lack of evidence for potentially beneficial treatments. There is a desperate need for large well conducted studies that evaluate long-term effects of current therapies. We suggest the creation of an international platform to improve quality and standardization of future trials in order to inform clinical practice.

Zinc supplementation for the treatment or prevention of disease: current status and future perspectives

Zinc is a nutritionally essential trace element, and thus zinc deficiency may severely affect human health. Many studies were published in which the effect of nutritional zinc supplementation on the incidence or severity of a certain disease was investigated. This review summarizes the main observations and aims to evaluate the use of nutritional zinc supplementation for prevention and treatment of human disease.

Cutaneous leishmaniasis

Cutaneous leishmaniasis is endemic in the tropics and neotropics. It is often referred to as a group of diseases because of the varied spectrum of clinical manifestations, which range from small cutaneous nodules to gross mucosal tissue destruction. Cutaneous leishmaniasis can be caused by several Leishmania spp and is transmitted to human beings and animals by sandflies. Despite its increasing worldwide incidence, but because it is rarely fatal, cutaneous leishmaniasis has become one of the so-called neglected diseases, with little interest by financial donors, public-health authorities, and professionals to implement activities to research, prevent, or control the disease. In endemic countries, diagnosis is often made clinically and, if possible, by microscopic examination of lesion biopsy smears to visually confirm leishmania parasites as the cause. The use of more sophisticated diagnostic techniques that allow for species identification is usually restricted to research or clinical settings in non-endemic countries. The mainstays of cutaneous leishmaniasis treatment are pentavalent antimonials, with new oral and topical treatment alternatives only becoming available within the past few years; a vaccine currently does not exist. Disease prevention and control are difficult because of the complexity of cutaneous leishmaniasis epizoology, and the few options available for effective vector control.

Cutaneous leishmaniasis treatment

The causative species of cutaneous leishmaniasis determines the clinical features and courses, and treatments. Intralesional or systemic antimonials are the gold standard for the treatment of these diseases. However, as for visceral leishmaniasis, other therapeutic options appear promising. Paromomycin ointments are effective in Leishmania major, L. tropica, L. mexicana, and L. panamensis lesions. In L. braziliensis localized leishmaniasis, both paromomycin and imiquimod may be topically applied. Oral fluconazole and zinc sulfate are useful in L. major. Oral azithromycin, effective in vitro and in mice, needs further investigation in human leishmaniasis. On the contrary, data with oral itraconazole are disappointing. Oral miltefosine, which is very effective in visceral leishmaniasis caused by L. donovani, appears ineffective in L. major and L. braziliensis infections. Intramuscular pentamidine is required for L. guyanensis cutaneous leishmaniasis, for which systemic antimony is not effective. Liposomal amphotericin B could be an alternative to antimony in south American cutaneous leishmaniasis with mucosal involvement (especially L. braziliensis and L. guyanensis infections).

Treatment of acute Old World cutaneous leishmaniasis: a systematic review of the randomized controlled trials

BACKGROUND

Cutaneous leishmaniasis (CL) is caused by different species of Leishmania and transmitted by the bite of infected sand flies. It is a health problem in many countries.

OBJECTIVE

This study was performed to assess the evidence for the efficacy of different therapeutic modalities for acute Old World CL, which is usually caused by L major and L tropica.

METHODS

Evidence was reviewed according to the hierarchy of evidence. Because there have been no published systematic reviews on this topic to date, the primary source of evidence was individual randomized controlled trials (RCTs). Multiple databases were systematically searched. Using independent double review and published quality review criteria, articles were rated as good, fair, or poor. Treatment benefit data were tabulated, and conclusions were based on the rated strength of published evidence.

RESULTS

In all, 50 RCTs met inclusion criteria consisting of 5515 patients in 119 study arms. Reviewed trials were highly variable in quality and methods and generally provide weak evidence for treatment of acute Old World CL.

LIMITATIONS

The quality of included studies was generally poor.

CONCLUSIONS

Well-designed randomized, double-blind, controlled trials should be designed and conducted to find better evidence for the treatment of acute Old World CL.

Zinc in skin pathology and care

OBJECTIVES

To assess the significance of zinc in the etiology of various dermatological conditions and examine the role of zinc as a mode of treatment for a wide range of dermatoses.

METHODS

Review of existing literature through searches using the PubMed site with zinc and the dermatosis in question as search words.

RESULTS

Severe zinc deficiency states such as acrodermatitis enteropathica are associated with a variety of skin manifestations, such as perioral, acral and perineal dermatitis. These syndromes can be reversed with systemic zinc repletion. In addition to skin pathologies which are clearly zinc-dependent, many dermatological conditions (e.g. dandruff, acne and diaper rash) have been associated and treated with zinc. Success rates for treatment with zinc vary depending on the disease, mode of application and zinc salt used. Usually, alternative modes of treatment are superior to zinc.

CONCLUSIONS

Generally, it seems that with the exception of systemic deficiency states, there is very little evidence to convincingly demonstrate the efficacy of zinc as a first-line treatment for any dermatological conditions. Further research is needed in order to establish the indications for zinc treatment in dermatology, optimal mode of delivery, type of compound and therapeutic indexes.

Oral zinc sulfate in the treatment of Behcet's disease: A double blind cross-over study

This was a randomized, controlled, double-blind trial of zinc sulfate in the treatment of Behcet's disease. Patients with Behcet's disease were recruited in this study between November 2001 and February 2003. A clinical manifestations index (CMI) was calculated for each patient. Serum zinc was estimated in all patients both at the beginning and monthly throughout the trial. Serum zinc levels were estimated from 30 healthy normal subjects matched for age and sex as a control group. Patients were randomly allocated to receive either 100 mg zinc sulfate or identical placebo tablet three times daily in a double-blind manner. After 3 months of starting treatment, patients were crossed over, that is, patients on placebo received zinc sulfate and vice versa. Mean serum zinc level in Behcet's disease patients was statistically significantly lower than mean serum zinc levels in healthy the control. In group A (started with zinc sulfate), the mean CMI started to decline directly after the first month of therapy with zinc sulfate to significantly lower levels. After shifting to placebo treatment in the fourth month, the mean of CMI started to rise again gradually but remained significantly lower than levels before therapy for the fourth and fifth months. In group B (started with placebo), the mean of CMI remained high for the first 3 months. After crossing over to zinc sulfate in the fourth month, the mean of CMI started to decrease after the fourth month. An inverse correlation between CMI and serum zinc level was found. No side-effects were seen in either group. In conclusion, zinc sulfate was found to be a good option in the treatment of Behcet's disease.

Oral zinc sulfate in the treatment of rosacea: A double-blind, placebo-controlled study

BACKGROUND

Rosacea is a skin problem not uncommonly encountered world-wide. There is a need for an effective and well-tolerated treatment for this disease.

OBJECTIVE

To evaluate the efficacy and side-effects of zinc sulfate in rosacea in a randomized, controlled, double-blind trial.

PATIENTS AND METHODS

Patients with rosacea who attended the outpatient Clinic of Dermatology and Venereology in Baghdad Teaching Hospital were recruited into this study between October 2002 and August 2004. A disease severity score was calculated for each patient. The patients were randomly allocated to receive either zinc sulfate 100 mg or identical placebo capsules three times per day. Zinc sulfate and placebo capsules were given in a double-blind manner. Following 3 months of starting the treatment, the patients crossed over, i.e. patients on placebo crossed over to zinc sulfate and those on zinc sulfate crossed over to placebo.

RESULTS

Twenty-five patients with rosacea were included in this study: 16 (64%) females and nine (36%) males. Nineteen patients completed the study: 11 (58%) females and eight (42%) males. Patient age ranged from 21 to 64 years with a mean +/- SD of 48.2 +/- 9.3 years. Duration of the disease ranged from 1 to 14 years with a mean +/- SD of 4.4 +/- 3.2 years. In the group started on zinc sulfate, the score before therapy ranged from 5 to 11 with a mean +/- SD of 8 +/- 2.0. The mean started to decrease directly after the first month of therapy with zinc sulfate to a significantly lower level. After shifting to placebo treatment, the mean started to rise gradually in the fifth month but remained significantly lower than the levels before therapy. In the group started on placebo, the score before therapy ranged from 5 to 9 with a mean +/- SD of 7 +/- 1.3. The mean remained high in the first 3 months of therapy while the patients were on placebo. After shifting to zinc sulfate, the mean started to decrease after the fourth month to significantly low levels. No important side-effects were reported apart from mild gastric upset in three (12%) patients on zinc sulfate.

CONCLUSION

Zinc sulfate was found to be a good option in the treatment of rosacea, as it was safe, effective and lacking important side-effects.

Leishmania major and Leishmania tropica: I the in vitro effects of an immunomodulator, S2-Complex

This study was undertaken to try to determine the possible anti-leishmanial activity of S2-Complex, an organic complex of copper chloride, ascorbic acid, and nicotinamide. The promastigotes, axenic amastigotes, and intracellular amastigotes of both Leishmania major and Leishmania tropica were incubated with different concentrations of S2-Complex. The EC50 for each form was calculated. Results show that all forms of the parasites were dose dependently inhibited by S2-Complex. The promastigotes of both parasites were the most resistant with highest EC50 followed by axenic amastigotes. While intracellular amastigotes were the most sensitive with the lowest EC50. These results indicate that S2-Complex has a direct anti-leishmanial effect. When mice were treated with S2-Complex or BCG for four days before harvesting the macrophages, and the macrophages infected with both L. major and L. tropica, they showed increased phagocytosis and increased parasite killing. The results of S2-Complex were not statistically different from the immunomodulating agent BCG. These results indicate that S2-Complex has an immunomodulating effect in addition to the direct anti-leishmanial effect.

Cutaneous leishmaniasis in the returning traveler

Infection with protozoan parasites of the genus Leishmania leads to a wide variety of clinical disease syndromes called leishmaniasis, or more appropriately the leishmaniases. The three major clinical syndromes are cutaneous leishmaniasis, mucosal leishmaniasis, and visceral leishmaniasis. All three of these syndromes have been documented in returning travelers. This article focuses on cutaneous leishmaniasis with some comment on mucosal leishmaniasis.

Zinc/copper imbalance reflects immune dysfunction in human leishmaniasis: an ex vivo and in vitro study

Background

The process of elimination of intracellular pathogens, such as Leishmania, requires a Th1 type immune response, whereas a dominant Th2 response leads to exacerbated disease. Experimental human zinc deficiency decreases Th1 but not Th2 immune response. We investigated if zinc and copper levels differ in different clinical forms of leishmaniasis, and if these trace metals might be involved in the immune response towards the parasite.

Methods

Blood was collected from 31 patients with either localized cutaneous (LCL), mucosal (ML) or visceral (VL) leishmaniasis, as well as from 25 controls from endemic and non-endemic areas. Anti-Leishmania humoral and cellular immune response were evaluated by quantifying specific plasma IgG, lymphoproliferation and cytokine production, respectively. Plasma levels of Cu and Zn were quantified by atomic absorption spectrophotometry.

Results

A significant decrease in plasma Zn was observed in all three patient groups (p < 0.01 for LCL and ML, p < 0.001 for VL), as compared to controls, but only VL (7/10) and ML (1/7) patients displayed overt Zn deficiency. Plasma Cu was increased in LCL and VL (p < 0.001) but not in ML, and was strongly correlated to anti-Leishmania IgG (Spearman r = 0.65, p = 0.0028). Cu/Zn ratios were highest in patients with deficient cellular (VL<<LCL<ML) and exacerbated humoral (VL>LCL>ML) immune response. Ex vivo production of parasite-induced IFN-γ was negatively correlated to plasma Cu levels in LCL (r = -0.57, p = 0.01). In vitro, increased Cu levels inhibited IFN-γ production.

Conclusions

1. Zn deficiency in VL and ML indicate possible therapeutic administration of Zn in these severe forms of leishmaniasis. 2. Plasma Cu positively correlates to humoral immune response across patient groups. 3. Environmentally or genetically determined increases in Cu levels might augment susceptibility to infection with intracellular pathogens, by causing a decrease in IFN-γ production.