Impetigo: an update

Medical Applications of Hydrogels in Skin Infections: A Review

Skin infections are common diseases for which patients seek inpatient and outpatient medical care. Globally, an increasing number of people are affected by skin infections that could lead to physical and psychological damage. Skin infections always have a broad spectrum of clinical presentations that require physicians to make an aggressive and accurate diagnosis for prescribing the proper symptomatic antimicrobials. In most instances, the treatment for skin infections mainly includes oral or topical anti-infective drugs. However, some of the classical anti-infective drugs have limitations, such as poor water solubility, low bioavailability, and poor targeting efficiency, which can lead to poor efficacy, adverse effects, and drug resistance. Therefore, research priorities should focus on the development of more effective drug delivery systems with new materials. Hydrogels are a highly multifunctional class of medical materials with potential applications in dermatology. Several hydrogel dressings with anti-infective functions have been formulated and demonstrated to improve the efficacy and tolerance of oral or topical classical anti-infective drugs to a certain degree. In this study, the medical applications of hydrogels for the treatment of various skin infections are systematically reviewed to provide an important theoretical reference for future research studies on the treatment options for skin infections.

Non-bullous Impetigo: Incidence, Prevalence, and Treatment in the Pediatric Primary Care Setting in Italy

Impetigo is a common skin infection in children. The worldwide prevalence in children is estimated to be 12%, but this may be lower since high-income countries are under-represented. This research aims to evaluate the incidence, prevalence, and management of children with non-bullous impetigo (NBI) residing in Italy. This retrospective cohort study included children up to 14 years of age enrolled in the Pedianet database from January 2004 to June 2018. Events were identified searching ICD9-CM codes (684 and 694.3) and free text fields for a diagnosis of NBI reported during a primary care visit. Diagnoses were manually validated, and events registered within 30-days after the index date were considered follow-ups. Incidence (IR) and prevalence (PR) rates of NBI were stratified by sex, age group, and calendar year. Topical and systemic antibiotic treatments were grouped based on ATC codes. 15,136 NBI episodes occurred in a total cohort of 225,979 children. The overall IR of NBI was 9.5 per 1,000 person-years, and children aged 1-4 years had the highest IR (13.2 per 1,000 person-years). A significant decrease in NBI IR from 13 per 1,000 person-years in 2004 to 7.46 per 1,000 person-years in 2018 (p < 0.0001) was noted. Most of the episodes were treated; systemic antibiotics were preferred over topical.

CONCLUSION

The prevalence of NBI in children in Italy is less than one third than the global estimate and the trend in time is decreasing. Over prescriptions of systemic antibiotics pose a threat to the diffusion of antimicrobial resistance.

Skin Microbiome-The Next Frontier for Probiotic Intervention

The skin is the largest organ in the human body, and it orchestrates many functions that are fundamentally important for our survival. Although the skin might appear to present a relatively inhospitable or even hostile environment, a multitude of commensals and also some potentially pathogenic microorganisms have successfully adapted to survive and/or thrive within the diverse ecological niches created by the skin's topographical architecture. Dysbiosis within these microbial populations can result in the emergence and pathological progression of skin diseases. Unsurprisingly, this has led to a new focus of research both for the medical dermatology and cosmetic industries that is concerned with modulation of the skin microbiome to help address common microbially mediated or modulated conditions such as acne, body odour, and atopic dermatitis. This review presents an overview of our current understanding of the complex relationship of the skin with its microbiome and then introduces the concept of probiotic intervention for the management of microbial dysbiosis within the skin ecosystem.

Antimonium crudum in pediatric skin conditions: A classical homeopathic case series

Homeopathic Antimonium crudum may be useful in many pediatric skin conditions if prescribed on symptom similarity. It may especially be helpful in reducing the use of antibiotics and steroids in this age-group if proven to be effective through larger scientific studies.

The Use of Ozenoxacin in Pediatric Patients: Clinical Evidence, Efficacy and Safety

Impetigo is the most common childhood skin infection in the world. There are two patterns of impetigo: nonbullous (or impetigo contagiosa) and bullous. The nonbullous type is due to Staphylococcus aureus and group A beta-haemolytic Streptococcus and occurs in 70% of impetigo cases. Impetigo is often a self-limited disease, but complications can sometimes occur. Therapy depends on the extent and site of the lesions and on the presence of systemic symptoms. The increase in multidrug resistance pathogens, such as methicillin-resistant Staphylococcus aureus, mupirocin-resistant Staphylococcus aureus or quinolone-resistant Staphylococcus aureus, requires the development of new antibiotics against these agents. The aim of this review is to evaluate the efficacy and safety of ozenoxacin in children compared to those of other approved topical antimicrobial therapies. The bactericidal activity against both susceptible and resistant organisms is a relevant feature of ozenoxacin because the bacterial strain and potential for resistance are generally not known at the beginning of therapy. Additionally, its minimal dermal absorption and its capability to reach high concentrations in the upper layers of the epidermidis agrees with the recommended practice aimed at avoiding the emergence of bacterial resistance in presence of a good safety profile. Further studies with real-life analyses and pharmacoeconomic evaluation are needed to confirm its role as first-line and second-line therapy in children with impetigo.

Preparation and characterization of a novel thermosensitive and bioadhesive cephalexin nanohydrogel: a promising platform for topical antibacterial delivery

OBJECTIVE

Impetigo is a common and highly contagious bacterial skin infection that mostly affects young children and infants. Herein, we report the development of a thermosensitive and bioadhesive in-situ hydrogel-forming system containing cephalexin-loaded nanoparticles (NPs) suitable for antibacterial drug delivery.

METHODS

The nanohydrogel was formulated using drug-loaded NPs and characterized by its physicochemical characteristics. Antibacterial activities of the cephalexin NPs and nanohydrogel were examined in vitro against Staphylococcus aureus (S. aureus). The ex vivo drug permeation study was performed using rat skin. Finally, this formulation was tested for in vivo antibacterial activity using superficial skin infections in rats.

RESULTS

The mean size and entrapment efficiency of the NPs were found to be 178 nm and 58%, respectively. The transmission electron microscopy analysis verified the formation of spherical NPs. The drug-loaded NPs showed an enhanced eradication effect against S. aureus according to the declined MIC values in comparison with the untreated drug. The ex vivo permeation profile of the cephalexin nanohydrogel showed a slow release pattern for 8 h. When applied on rat skin for 6 days, the nanohydrogel exhibited a superior antibacterial activity with normal hair growth and skin appearance as compared to the plain drug hydrogel.

CONCLUSIONS

These findings suggested that the nanohydrogel could serve as a valuable drug delivery platform against superficial bacterial infections.

Safety and efficacy profile of ozenoxacin 1% cream in pediatric patients with impetigo

Background

Ozenoxacin is a topical antibiotic approved in the United States for treatment of impetigo in adults and children age ≥2 months. This analysis evaluated the efficacy and safety of ozenoxacin in specific pediatric age groups.

Methods

Data for children aged 2 months to <18 years recruited from eight countries who had participated in phase 1 and 3 trials of ozenoxacin were extracted and analyzed by age range.

Results

Across studies, 644 pediatric patients with impetigo received ozenoxacin 1% cream (n = 287) or vehicle (n = 247). One study included retapamulin 1% ointment as the internal validity control (n = 110). The clinical success rate at the end of treatment and bacterial eradication rates after 3 to 4 days of treatment and at the end of treatment were significantly higher with ozenoxacin than vehicle (all p < .0001). The clinical and microbiologic success rates were higher with ozenoxacin than vehicle in the age groups of 0.5 to <2 years, 2 to <6 years, 6 to <12 years, and 12 to <18 years and were comparable to vehicle in the 2 to <6 months age group, although patient numbers were low (≤5 per treatment arm). No safety concerns with ozenoxacin were identified. Of the 362 plasma samples derived from 38 patients, four slightly exceeded the lower limit of quantification, indicating negligible systemic absorption.

Conclusion

The results of this analysis suggest that ozenoxacin 1% cream is an effective and safe treatment for impetigo in pediatric patients aged 2 months to <18 years.

Efficacy and Safety of Ozenoxacin Cream for Treatment of Adult and Pediatric Patients With Impetigo: A Randomized Clinical Trial

Importance

Ozenoxacin, a novel topical antibacterial agent with potent bactericidal activity against gram-positive bacteria, has been developed as a cream with 1% active drug for the treatment of impetigo, a highly contagious bacterial skin infection.

Objectives

To evaluate the efficacy, safety, and tolerability of ozenoxacin cream, 1%, after 5-day twice-daily topical treatment in patients with impetigo.

Design, Setting, and Participants

This randomized, double-blind, vehicle-controlled clinical trial included patients 2 months or older with impetigo who were enrolled at centers in 6 countries from June 2, 2014, through May 30, 2015. Data were analyzed based on intention to treat from July 9 through July 22, 2015.

Interventions

Patients were randomized 1:1 to receive topical ozenoxacin or placebo control.

Main Outcomes and Measures

Efficacy was measured using the Skin Infection Rating Scale and microbiological culture. Safety and tolerability were also evaluated.

Results

Among the 411 patients who received treatment (210 males [51.1%]; mean [SD] age, 18.6 [18.3] years), ozenoxacin demonstrated superior clinical success compared with placebo, which was evident after 5 days of therapy (112 of 206 [54.4%] vs 78 of 206 [37.9%]; P = .001). Ozenoxacin also demonstrated superior microbiological success compared with placebo after 2 days of therapy (109 of 125 [87.2%] vs 76 of 119 [63.9%]; P = .002). Ozenoxacin was well tolerated, with 8 of 206 patients experiencing adverse effects, with only 1 of these potentially related to the study treatment; none were serious.

Conclusions and Relevance

Topical ozenoxacin is effective and well tolerated in the treatment of impetigo in patients 2 months and older. This effect is demonstrated by rapid onset of response and superior clinical and microbiological response compared with placebo. Topical ozenoxacin represents a novel option for the treatment of impetigo.

Trial Registration

ClinicalTrials.gov Identifier: NCT02090764.

Ozenoxacin: a review of preclinical and clinical efficacy

INTRODUCTION

Impetigo is the most common bacterial skin infection in children. Treatment is becoming complicated due to the development of antimicrobial resistance, especially in the main pathogen, Staphylococcus aureus. Ozenoxacin, a novel non-fluorinated topical quinolone antimicrobial, has demonstrated efficacy in impetigo. Areas covered: This article reviews the microbiology, pharmacodynamic and pharmacokinetic properties of ozenoxacin, and its clinical and microbiological efficacy in impetigo. Expert opinion: In an environment of increasing antimicrobial resistance and concurrent slowdown in antimicrobial development, the introduction of a new agent is a major event. Ozenoxacin is characterized by simultaneous affinity for DNA gyrase and topoisomerase IV, appears to be impervious to certain efflux pumps that confer bacterial resistance to other quinolones, shows low selection of resistant mutants, and has a mutant prevention concentration below its concentration in skin. These mechanisms protect ozenoxacin against development of resistance, while the absence of a fluorine atom in its structure confers a better safety profile versus fluoroquinolones. In vitro studies have demonstrated high potency of ozenoxacin against staphylococci and streptococci including resistant strains of S. aureus. Clinical trials of ozenoxacin in patients with impetigo reported high clinical and microbiological success rates. Preserving the activity and availability of ozenoxacin through antimicrobial stewardship is paramount.

Ozenoxacin: A Novel Drug Discovery for the Treatment of Impetigo

OBJECTIVE

Ozenoxacin is one of the potent quinolone antibiotics, recently approved by the United States Food and Drug Administration (USFDA) with reported pharmacology to treat the impetigo. The demand for better acting topical formulation is increasing day by day. The present review is an attempt to summarize the facts behind the chemistry and biological applications of Ozenoxacin. Mechanism of Action: This novel drug being a quinolone antibiotic compound, acts by inhibiting DNA gyrase A and topoisomerase IV and affects supercoiling, supercoil relaxation, chromosomal condensation, chromosomal decatenation and many others. Pharmacology: Ozenoxacin has demonstrated to have a bactericidal activity against organisms, such as Staphylococcus aureus and Staphylococcus pyogenes. Ozenoxacin is non-fluorinated quinolone and being developed for the other dermatological bacterial infections as well. No sign of genotoxicity was observed when tested experimentally.

CONCLUSION

The present review also covers the complete picture of pharmacokinetics, clinical trials, toxicity and future scope and possible avenues in this arena.

Skin Infections

The primary care provider will commonly see skin and soft tissue infections in the outpatient setting. Skin and soft tissue infections range from the uncomplicated impetigo to the potentially lethal necrotizing fasciitis. This article reviews these infections based on their underlying etiology: bacterial, fungal, and viral causes. This article discusses the etiology, presentation, evaluation, and management of impetigo, bullous impetigo, erysipelas, cellulitis, periorbital cellulitis, orbital cellulitis, folliculitis, furuncles, carbuncles, abscess, necrotizing fasciitis, sporotrichosis, tinea corporis, tinea pedis, tinea capitis, Herpes Simplex Virus, zoster, molluscum contagiosum, and warts.

PUSTULAR DERMATITIS CAUSED BY IMPETIGO IN RED-TAILED MONKEYS ( CERCOPITHECUS ASCANIUS)

Impetigo is a bacterial infection of the superficial layer of the epidermis with crusting or bullae caused by Streptococcus spp., Staphylococcus spp., or both. A 14-yr-old red-tailed monkey ( Cercopithecus ascanius) presented with recurrent scabbing and ulceration under the nares over an 8-yr period. Repeated cultures and biopsy samples led to a presumptive diagnosis of impetigo, later confirmed on necropsy. Multiple antibiotic regimens were employed with varying success during multiple episodes, while lesions resolved on their own at other times. This condition has not been previously reported in a nonhuman primate, although it is not uncommon in humans.

Advances in pharmacotherapeutic management of common skin diseases in neonates and infants

INTRODUCTION

neonatal and infantile skin diseases are frequently encountered in the clinical practice and represent worldwide a socioeconomic issue. They encompass a wide range of acquired or congenital conditions, including infections, vascular lesions and inflammatory diseases and can present with different degrees of severity, leading in some cases to dramatic complications. Areas covered: In this paper we report the most recent evidences on the management of some common skin diseases in neonates and infants. Hemangiomas, viral, fungal and bacterial infections, omphalitis, atopic and seborrhoeic dermatitis, napkin disease will be treated and discussed. Expert opinion: The majority of the dermatologic alterations in neonates are physiological, transient and do not require any treatment, thus the parents can be reassured about the good prognosis. However, in some cases, serious conditions must be excluded. In particular neonatal and infantile infections should be promptly recognized and properly managed, to avoid severe complications. The therapeutic options include traditional and, although few, innovative medical treatments, which will be carefully taken into consideration by the expert Dermatologists and Paediatricians.

Childhood skin and soft tissue infections: new discoveries and guidelines regarding the management of bacterial soft tissue infections, molluscum contagiosum, and warts

PURPOSE OF REVIEW

Pediatric skin and soft tissue infections (SSTIs) constitute a significant number of office-based pediatric visits. With SSTIs on the rise, it is not only important to effectively treat the individual, but to do so appropriately and cost-consciously. In this article, we highlight new research related to the treatment of bacterial skin infections, molluscum contagiosum, and cutaneous warts, with the goal of guiding pediatricians in their practice against these common skin conditions.

RECENT FINDINGS

Recent data supports the use of topical antibiotics for noncomplicated impetigo. Systemic antibiotics covering gram-positive cocci are recommended for complicated cases of impetigo and deeper nonpurulent SSTIs. Localized purulent bacterial SSTIs can be treated with incision and drainage alone but more systemic involvement warrants treatment with systemic antibiotics covering Staphylococcus aureus species, especially community acquired methicillin-resistant S. aureus. For the treatment of molluscum contagiosum, topical cantharidin has a high satisfaction rate among patients and providers. Potassium hydroxide solution is a potentially effective and cheap form of molluscum contagiosum treatment. Imiquimod, however, has an unfavorable efficacy and safety profile as a therapy for molluscum contagiosum. Regarding warts, high-risk human papilloma virus strains have been detected in cutaneous warts in children.

SUMMARY

The high-risk human papilloma virus vaccine may play a role in treating pediatric cutaneous warts in the future, and topical squaric acid dibutylester may effectively treat recalcitrant warts. Finally, both molluscum contagiosum and warts have a high rate of resolution after an extended period of time without any intervention.

Fabric-skin models to assess infection transfer for impetigo contagiosa in a kindergarten scenario

Children in community bodies like kindergartens are predisposed to suffer from impetigo. To consider important measures for infection prevention, direct and indirect transmission routes of pathogens must be revealed. Therefore, we studied the role of skin and fabrics in the spread of the impetigo pathogen Staphylococcus aureus and the strain Streptococcus equi (surrogate to Streptococcus pyogenes) in order to assess infection transfer in realistic scenarios. The transmission of test strains was studied with standardized fabric-skin models using a technical artificial skin and fabrics of different fiber types commonly occurring in German kindergartens. In synthetic pus, both test strains persisted on artificial skin and fabrics for at least 4 h. Friction enhanced transfer, depending on the fiber type or fabric construction. In a skin-to-skin setup, the total transfer was higher than via fabrics and no decrease in the transmission rates from donor to recipients could be observed after successive direct skin contacts. Children in kindergartens may be at risk of transmission for impetigo pathogens, especially via direct skin contact, but also by the joint use of fabrics, like towels or handicraft materials. Fabric-skin models used in this study enable further insight into the transmission factors for skin infections on the basis of a practical approach.

Impetigo - review

Impetigo is a common cutaneous infection that is especially prevalent in children. Historically, impetigo is caused by either group A β-hemolytic streptococci or Staphylococcus aureus. Currently, the most frequently isolated pathogen is S. aureus. This article discusses the microbiologic and virulence factors of group A β-hemolytic streptococci and Staphylococcus aureus, clinical characteristics, complications, as well as the approach to diagnosis and management of impetigo. Topical agents for impetigo therapy are reviewed.

Topical Antibiotic Treatment of Impetigo with Tetracycline

Forty-nine children aged 0.2-13 years with bullous and eroded lesions, from which Staphylococcus aureus was isolated, were diagnosed with impetigo and entered into a randomized, open-labeled trial of topical oxytetracycline hydrochloride (tetracycline) compared with a combination of topical tetracycline and oral antibiotics. After one week of topical tetracycline treatment, 22 of the 28 patients were clinically cured, and the remaining six patients had improved. In the other treatment group, 14 patients of 21 were clinically cured and 7 patients improved by the combination of topical tetracycline and oral antibiotics. There were no significant differences between the two groups. Therefore, the present study suggests that topical tetracycline treatment is effective for the treatment of impetigo.

In vitro antibacterial activity of E-101 Solution, a novel myeloperoxidase-mediated antimicrobial, against Gram-positive and Gram-negative pathogens

OBJECTIVES

E-101 Solution (E-101) is a novel myeloperoxidase-mediated antimicrobial. It is composed of porcine myeloperoxidase (pMPO), glucose oxidase, glucose as the substrate and specific amino acids in an aqueous vehicle. E-101 is being developed for topical application directly into surgical wounds to prevent surgical site infections (SSIs). The in vitro activity of E-101 was investigated.

METHODS

MIC, MBC, time-kill and antimicrobial combination experiments were performed according to CLSI guidelines with modifications. Resistance selection studies were performed using a serial passage method.

RESULTS

E-101 showed MIC(90) values of 0.03, 0.5 and 0.5 mg pMPO/L for staphylococci (n = 140), streptococci (n = 95) and enterococci (n = 55), respectively. MIC(90) values ranged between 0.03-0.5 and ≤ 0.004-0.12 mg pMPO/L for Enterobacteriaceae (n = 148) and Gram-negative non-Enterobacteriaceae (n = 92) strains, respectively. There was no antimicrobial tolerance to E-101 for Staphylococcus aureus, Streptococcus agalactiae or Streptococcus pyogenes. Time-kill studies demonstrated a rapid (<30 min) bactericidal effect against S. aureus, Enterococcus faecalis, Escherichia coli and Pseudomonas aeruginosa in a concentration-dependent and time-dependent manner. There was no evidence of stable resistance to E-101 among staphylococci, enterococci, E. coli or P. aeruginosa strains and no evidence of E-101 interaction with antibiotics commonly used in clinical medicine. Conclusions E-101 shows potent and broad-spectrum in vitro activity against bacteria that are the causative pathogens of SSIs, thereby providing the impetus to test its clinical utility in the prevention of SSIs.

Skin infections in developing countries

PURPOSE OF REVIEW

In developing countries, where the majority of people have a low income and live in resource-poor settings, skin infections are prevalent. Data from recent studies provide insight into the most common skin infections and their management.

RECENT FINDINGS

Several studies confirm that skin infections account for the majority of pediatric mortality and morbidity in developing countries. They are prevalent in resource-poor settings and rural areas in certain parts of the world. Also, hot, humid climates and overcrowding predispose to skin infections. Most of the skin infections are curable with effective medication.

SUMMARY

Skin infections are of particular importance in developing countries. This review focuses on the most common skin infections and summarizes the most recent knowledge on the epidemiology, morbidity, and treatment in resource-poor settings.

Increasing hospitalizations and general practice prescriptions for community-onset staphylococcal disease, England

Infections requiring hospitalization and community prescriptions have increased dramatically since 1989.

Rates of hospital-acquired staphylococcal infection increased throughout the 1990s; however, information is limited on trends in community-onset staphylococcal disease in the United Kingdom. We used Hospital Episode Statistics to describe trends in hospital admissions for community-onset staphylococcal disease and national general practice data to describe trends in community prescribing for staphylococcal disease. Hospital admission rates for staphyloccocal septicemia, staphylococcal pneumonia, staphylococcal scalded-skin syndrome, and impetigo increased >5-fold. Admission rates increased 3-fold for abscesses and cellulitis and 1.5-fold for bone and joint infections. In primary care settings during 1991–2006, floxacillin prescriptions increased 1.8-fold and fusidic acid prescriptions 2.5-fold. The increases were not matched by increases in admission rates for control conditions. We identified a previously undescribed but major increase in pathogenic community-onset staphylococcal disease over the past 15 years. These trends are of concern given the international emergence of invasive community-onset staphylococcal infections.

Selection of retapamulin, a novel pleuromutilin for topical use

The in vitro activity of retapamulin was determined and compared to that of topical and community antibiotics. The MIC(90)s of retapamulin against Staphylococcus aureus and Streptococcus pyogenes were 0.12 microg/ml and 0.016 microg/ml, respectively. Retapamulin has a low propensity to select resistance and produces an in vitro postantibiotic effect.

Recurrent staphylococcal conjunctivitis associated with facial impetigo contagiosa

PURPOSE

To report the uncommon occurrence of impetigo contagiosa in the setting of recurrent staphylococcal conjunctivitis.

DESIGN

Interventional case report.

METHODS

A 32-year-old patient had a recurrent painful red left eye and facial rash. Clinical examination revealed left bacterial conjunctivitis and facial bullous impetigo. Microbiology cultures were taken from the nose, conjunctiva, and facial lesions.

RESULTS

Microbiologic cultures grew Staphylococcus aureus, and hematology findings demonstrated an elevated white cell count with neutrophilia. Complete resolution was achieved with topical chloramphenicol ointment and oral dicloxacillin.

CONCLUSIONS

Although uncommon, bullous impetigo may be associated with recurrent staphylococcal conjunctivitis in adults. Recurrent infections may require nasal decolonization, systemic antibiotics, and antiseptic body wash.

The intraepidermal blistering conditions

The intraepidermal vesiculobullous disorders constitute a wide variety of pathogenically unrelated disorders that share in common the formation of cleft or bullae formation within the epithelium. The etiologic, pathogenic, clinical and, in particular, the histopathologic attributes of the most important intraepidermal blistering conditions are described.