Role of antifungal agents in the treatment of seborrheic dermatitis

Scalp Seborrheic Dermatitis: What We Know So Far

Scalp seborrheic dermatitis (SSD) is a prevalent chronic, relapsing inflammatory skin disease. The etiology is related to sebum production, bacterial proliferation - Staphylococcus sp., Streptococcus, and M. restricta - and host immunity factors - NK1+, CD16+ cells, IL-1, and IL-8. Trichoscopy features include mostly arborizing vessels and yellowish scales. New trichoscopic findings were described to guide the diagnosis as dandelion vascular conglomerate, "cherry blossom" vascular pattern, and intrafollicular oily material. Antifungals and corticosteroids constitute the essential therapy, but new treatments have been described. This article aims to review and discuss the etiology, pathophysiology, trichoscopy, histopathologic findings, main differential diagnoses, and therapeutic options of SSD.

Herbal Therapy for the Management of Seborrheic Dermatitis: A Narrative Review

INTRODUCTION

Dandruff and Seborrheic Dermatitis (SD) are similar skin conditions with different degrees ofseverity. Since the current therapies cannot remove dandruff efficiently, herbal extracts with better effectiveness and fewer side effects are used in the pharmaceutical and cosmetic industries. Due to the adverse effects of chemical drugs, the use of natural products and traditional medicine has significantly increased over the past few decades. Therefore, in this review, we reported the herbs used as anti-dandruff agents in traditional medicine worldwide.

METHODS

The review was conducted on the literature available on the medicinal utility of certain plants as anti-dandruff agents using PubMed and Google Scholar and the following search terms: Dandruff and plants or medicinal plant and dandruff treatment, and essential oil and dandruff.

RESULTS

Since the current therapies cannotefficiently remove dandruff, herbal extracts with better effectiveness and fewer side effects are used in the pharmaceutical and cosmetic industries. Nowadays, there are numerous different types of herbal antidandruff shampoos. They are effective and safe without the side effects of chemical agents. Recently, herbal medicine has attracted a great deal of scientific attention. Clinical evidence on the therapeutic effects of herbal products has resulted in the study of far more herbs for their therapeutic roles.

CONCLUSION

Herbal therapy plays a significant role in the development of favorable therapeutics, either alone or in combination with conventional antibiotics. However, the major challenges in this regard include finding compounds with satisfactorily lower MICs, low toxicity, and high bioavailability for effective and safe use in humans and animals.

Tacrolimus 0.1% versus ciclopiroxolamine 1% for maintenance therapy in patients with severe facial seborrheic dermatitis: A multicenter, double-blind, randomized controlled study

BACKGROUND

No long-term maintenance therapy has been tested in patients with seborrheic dermatitis (SD).

OBJECTIVE

We sought to compare the efficacy and tolerance of tacrolimus 0.1% ointment versus ciclopiroxolamine 1% cream as maintenance therapy for severe SD.

METHODS

This double-blind randomized controlled study was conducted from 2014 to 2017 in 5 Dermatology Departments and 15 dermatology practices in France. Consecutive patients with severe and chronic facial SD were included. Patients were initially treated with desonide 0.05% cream twice daily for 7 days. Patients cleared after this open phase were randomized to receive tacrolimus 0.1% or ciclopiroxolamine 1% cream 2 times a week 24 weeks. The primary endpoint was disease-free-duration, defined as the time from randomization to first relapse.

RESULTS

One hundred fourteen patients were randomized (tacrolimus, n = 57; ciclopiroxolamine, n = 57). Twelve patients relapsed in the tacrolimus group after a median delay of 91.5 days (range 15-195 days) versus 23 patients in the ciclopiroxolamine group (median delay, 27 days [range 13-201 days]). Comparison of disease-free duration curves showed that patients in the tacrolimus group had a longer duration of complete remission than those in the ciclopiroxolamine group (P = .018), corresponding to a hazard ratio of relapse of 0.44 (95% confidence interval 0.22-0.89; P = .022).

LIMITATIONS

The theoretical sample size was not reached.

CONCLUSION

Tacrolimus 0.1% is more effective than ciclopiroxolamine 1% as maintenance therapy for patients with facial SD.

Clinical characteristics and quality of life in seborrheic dermatitis patients: a cross-sectional study in China

Background

Seborrheic dermatitis (SD) is a common, chronic, inflammatory skin disorder, yet few studies have reported its clinical characteristics, or addressed its effect on quality of life (QoL). This study assesses the clinical characteristics and QoL of SD patients in China. It also identifies the clinical, demographic and environmental factors that may influence QoL.

Methods

Three hundred twelve SD outpatients from 9 hospitals completed a survey. QoL was measured with the dermatology-specific instrument Skindex-29. We collected social demographic characteristics and disease severity, and conducted logistic regression to determine the factors associated with QoL impairment.

Results

67.3% of the patients were females. The mean Skindex-29 overall score was 33.97 (SD = 20.55). The breakdown was 40.79 (SD = 24.24) for emotions, 32.83 (SD = 19.84) for symptoms and 28.3 (SD = 23.24) for functioning. 48.1% had severe emotional problems. Logistic regression analysis showed that BMI less than 25 (OR = 0.223; 95% CI: 0.072–0.692; P = 0.009), skin disease-related hospitalization (OR = 6.882; 95% CI:1.767–26.795; P = 0.005), environmental PM 10 levels above 120 μg/m³ (OR = 3.386; 95% CI: 1.253–9.15; P = 0.016) and severe disease conditions (OR = 4.438; 95% CI:1.26–15.626; P = 0.02) were risk factors for severe emotional impairment. Moreover, skin disease-related hospitalization (OR = 6.057; 95% CI:1.351–27.149; P = 0.019), environmental PM 10 levels between 70 and 120 μg/m³ (OR = 6.317; 94% CI: 1.704–23.42; P = 0.006), moderate (OR = 2.388; 95% CI: 1.272–4.487; P = 0.007) and severe disease conditions (OR = 5.732; 95% CI: 1.838–17.88; P = 0.003) were each risk factors for overall severe impairment.

Conclusion

In China, nearly half of SD patients had severely emotional problems. Disease severity, BMI, dermatologic hospitalization, and ambient PM 10 levels are each risk factors for QoL impairment in SD patients. These implications are alarming, and warrant public health attention in SD disease management.

Exploring Anti-Fungal, Anti-Microbial and Anti-Inflammatory Properties of a Topical Non-Steroidal Barrier Cream in Face and Chest Seborrheic Dermatitis

INTRODUCTION

The pathogenesis of seborrheic dermatitis (SD) is multifactorial and traditional treatments may not target all aspects of it. The aim of this study was to evaluate short-term anti-fungal, anti-microbial, anti-inflammatory and anti-pruritus properties of a novel non-steroidal cream (NSC) containing piroctone olamine, zinc salt of L-pyrrolidone carboxylate (PCA), hydroxyphenyl propamidobenzoic acid, biosaccharide gum-2 and stearyl glycyrrhetinate in patients with face and chest SD.

METHODS

Twelve male subjects affected by SD, presenting face and chest manifestations, were enrolled. Patients were instructed to apply NSC twice a day, performing regular visits at baseline (W0), after 7 (W1) and 14 (W2) days of treatment. A limitation of the study was that no control group treated with the vehicle without active ingredients was enrolled. To evaluate the efficacy of the NSC, investigator's assessments were represented by scoring index (SI) and investigator's global assessment score (IGA). In order to assess NSC anti-fungal and anti-microbial effects, skin scale scrapings were collected and used for Malassezia furfur (MF) and Staphylococcus epidermidis (SE) cultures. In parallel, in order to assess NSC anti-inflammatory effects, gene expression of IL-1α, IL-1β, IL-6, IL-8, and TNF-α was assessed. In addition, anti-pruritus effects were also evaluated through gene expression of cathepsin S and L-histidine decarboxylase.

RESULTS

SI mean scores significantly decreased at W1 and, to a greater extent, at W2 compared with W0. The IGA score registered an important improvement efficacy both for face and chest, from W1 to W2. MF and SE growth was already inhibited at W1, with a more pronounced decrease at W2. Gene expression of all analyzed mediators was significantly reduced at W1 compared to W0.

CONCLUSION

In conclusion, our assessment is that NSC is an effective and well tolerated treatment option for SD with anti-fungal, anti-microbial and anti-inflammatory properties.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN77871064 (retrospectively registered October 17, 2019). EudraCT number, 2019-003813-32.

FUNDING

ISDIN.

Flavonoid Composition of Salacia senegalensis (Lam.) DC. Leaves, Evaluation of Antidermatophytic Effects, and Potential Amelioration of the Associated Inflammatory Response

Predominantly spread in West Tropical Africa, the shrub Salacia senegalensis (Lam.) DC. is known because of its medicinal properties, the leaves being used in the treatment of skin diseases. Prompted by the ethnomedicinal use, a hydroethanolic extract obtained from the leaves of the plant was screened against a panel of microbial strains, the majority of which involved in superficial infections. The extract was found to be active against the dermatophytes Trichophyton rubrum and Epidermophyton floccosum. Notable results were also recorded regarding the attenuation of the inflammatory response, namely the inhibitory effects observed against soybean 5-lipoxygenase (IC₅₀ = 71.14 μg mL^-1), no interference being recorded in the cellular viability of RAW 264.7 macrophages and NO levels. Relevantly, the extract did not lead to detrimental effects against the keratinocyte cell line HaCaT, at concentrations displaying antidermatophytic and anti-inflammatory effects. Flavonoid profiling of S. senegalensis leaves was achieved for the first time, allowing the identification and quantitation of myricitrin, three 3-O-substituted quercetin derivatives, and three other flavonoid derivatives, which may contribute, at least partially, to the observed antidermatophytic and anti-inflammatory effects. In the current study, the plant S. senegalensis is assessed concerning its antidermatophytic and anti-inflammatory properties.

Effects of a cream containing 5% hyaluronic acid mixed with a bacterial-wall-derived glycoprotein, glycyrretinic acid, piroctone olamine and climbazole on signs, symptoms and skin bacterial microbiota in subjects with seborrheic dermatitis of the face

Objective: A new cream formulation containing hyaluronic acid 5%, complexed with a mix of a bacterial-wall-derived glycoprotein and peptide glycan complex (EDS), has been recently developed. We evaluated in a prospective, assessor-blinded, 6-week study the efficacy and tolerability of EDS in the treatment of facial seborrheic dermatitis (SD) and the effects on skin microbiota.

Subjects and methods: Seventy-five subjects (mean age 46; 60 men) with moderate-severe SD of the face were enrolled. EDS cream was applied twice daily. The primary outcome was the evolution of the Investigator Global Assessment (IGA) score, evaluating erythema, scale/flaking, grade of seborrhea and itch. Superficial skin bacterial microbiome at baseline and after treatment was assessed, using the 16S rRNA gene methodology, in affected and non-affected face areas. Local tolerability was evaluated checking self-reported side effects at each visit.

Results: Baseline IGA scores (mean±SD) was 10±3. The use of EDS reduced IGA score significantly by 70% at week 3 and by 88% at week 6. An increase in the abundance of Cutibacterium acnes genera associated with a significant drop of Staphylococcus genera presence was detected in affected areas. The ratio of relative abundance of genera Cutibacterium/Staphylococcus increased significantly after treatment in affected areas. The product was very well tolerated.

Conclusion: Treatment with EDS applied twice daily for 6 consecutive weeks was associated with a reduction of the signs and symptoms of SD. Furthermore, after EDS cream treatment, a reequilibrating effect on facial skin microbiota was observed. The product was very well tolerated.

Interventions for infantile seborrhoeic dermatitis (including cradle cap)

BACKGROUND

Infantile seborrhoeic dermatitis (ISD) is a chronic, inflammatory, scaling skin condition, which causes redness and a greasy scaling rash in infants and young children. It can last from weeks to months, but rarely years. When it occurs on the scalp, it is referred to as 'cradle cap'. While benign and self-limiting, irrelevant of its location on the body, it can distress parents. The effectiveness of commonly promoted treatments is unclear.

OBJECTIVES

To assess the effects of interventions for infantile seborrhoeic dermatitis in children from birth to 24 months of age.

SEARCH METHODS

We searched the following databases up to 22 May 2018: Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We searched trials registers and checked reference lists of included studies for further references to randomised controlled trials (RCTs). We searched for unpublished RCTs and grey literature via web search engines, and wrote to authors and pharmaceutical companies.

SELECTION CRITERIA

We included RCTs of interventions for ISD in children from birth up to 24 months who were clinically diagnosed by a healthcare practitioner with ISD or cradle cap. We allowed comparison of any treatment to no treatment or placebo, and the comparison of two or more treatments or a combination of treatments.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. The primary outcome measures were 'Change in severity score from baseline to end of study' and 'Percentage of infants treated who develop adverse effects or intolerance to treatment'. The secondary outcome was 'Improvement in quality of life (QoL) as reported by parents'.

MAIN RESULTS

We included six RCTs (one with a cross-over design) randomising 310 children and reporting outcomes for 297 children. Most participants were aged under seven months with only two participants aged over one year (seven and 12 years old); where specified, 60% were boys. In two studies, condition severity was mild to moderate; one study included two participants with severe ISD; the other studies did not describe baseline severity or described it as body surface area affected.The study setting was not always clear but likely a paediatric outpatient clinic in the following countries: Thailand, Israel, USA, France, and Australia.Two studies compared oral biotin (a B group vitamin) against placebo, two studies compared proprietary products against placebo cream or a control shampoo, and two studies compared topical corticosteroids against other products. The studies were generally short-term, between 10 and 42 days' duration; only one study followed the participants until resolution of the rash or eight months of age.We assessed the risk of bias as unclear for most aspects due to lack of reporting, but two of the studies were at high risk of performance and detection bias due to the appearance of the intervention, the trial design (open-label), or use of overlabelled tubes. Two trials had a high risk of attrition bias.All the results given below were based on very low-quality evidence. Treatment duration ranged from one week to three weeks.For the two trials comparing biotin versus placebo (n = 35), one did not report a measure of change in severity (only change in duration of rash) while the other did not report raw data (only 'no statistically significant difference'), measured at three weeks. Neither trial reported on adverse events.Two trials compared proprietary products against placebo (n = 160). One trial assessed change in severity via percentage success (96% of participants in non-steroidal cream Promiseb versus 92% in placebo), and reported no adverse events (both assessed at day 14). The other trial assessed change in severity via reduction in lesional score (surface area covered), finding better results for lactamide MEA gel (a moisturising agent) plus shampoo (81.4%) compared with shampoo only (70.2%; P = 0.0092). No adverse events were described, but signs of discomfort were similar in both groups (both assessed at day 21).In the comparison of topical steroids versus another product, change in severity was measured through evaluation of cure and body surface (n = 102).In one trial comparing hydrocortisone 1% lotion with licochalcone 0.025% lotion, there was no significant difference in participants cured (95.8% with hydrocortisone compared to 97.1% with licochalcone). One person in the licochalcone group developed more erythema, but there were no other adverse events (both outcomes assessed at day 14). In the trial comparing flumethasone pivalate 0.02% ointment versus eosin 2% aqueous solution, a reduction in body surface area affected was seen in both groups at day 10 (9% with corticosteroid versus 7% with aqueous solution), with all infants showing less than 10% involvement. There were no adverse events (both outcomes assessed at day 10).No studies measured QoL.We found no trials testing commonly used treatments such as mineral oils, salicylic acid, or antifungals.

AUTHORS' CONCLUSIONS

Our review identified only a limited number of studies investigating the effects of interventions for ISD in infants and young children. Unlike the reviews investigating the effects of treatments in adults, our results showed that there is uncertainty regarding the effectiveness and safety of studied treatments due to the very low-certainty evidence for all comparisons and outcomes.We assessed most bias domains as at unclear risk, but there was a high risk of bias for (mainly) performance, attrition, and detection bias. Evidence was limited further by imprecision (small studies, low number of events), indirectness (mainly with the outcomes assessed), and poor trial reporting. In most studies, the prognosis for the condition was favourable regardless of intervention but interpretation is limited by the very low-certainty evidence.Further research is needed with large, well-conducted, and well-reported intervention trials, particularly of interventions commonly recommended or used, such as emollients or shampoos and brushing, antifungals, or steroids. All studies should report standardised and validated relevant outcome measures, including adverse events, severity, and QoL, and they should be conducted in primary care settings where the majority of ISD is managed. Future trials should compare against placebo, no treatment, or standard care.

Trabecular meshwork cells are a valuable resource for cellular therapy of glaucoma

Trabecular meshwork (TM) contains a subset of adult stem cells or progenitors that can be differentiated into corneal endothelial cells, adipocytes and chondrocytes, but not osteocytes or keratocytes. Accordingly, these progenitors can be utilized as a cell‐based therapy to prevent blindness caused by glaucoma, corneal endothelial dysfunction and other diseases in general. In this review, we review in vitro expansion techniques for TM progenitors, discuss their phenotypic properties, and highlight their potential clinical applications in various ophthalmic diseases.

Commercial Essential Oil Combinations against Topical Fungal Pathogens

Essential oils are amongst the most popular natural products recommended for the treatment of topical fungal infections. This study investigated the antifungal activity of 128 essential oil combinations against fungal pathogen reference strains using the broth microdilution technique to determine the minimum inhibitory concentration (MIC). The essential oils were investigated at a volume of 100 μL and the combinations comprised of 50:50 μL. Each combination was tested in triplicate and the mean recorded. The fractional inhibitory concentration index was calculated for combinations, and synergistic interactions were investigated further at different ratios and plotted on isobolograms. The fungal pathogens were found to be highly susceptible to the essential oil combinations, with Trichophyton mentagrophytes being inhibited by all but one combination. The essential oil combinations containing Cinnamomum verum or Santalum austrocaledonicum were found to display the strongest inhibition with MIC values as low as 0.06 mg/mL. Potential combinations against fungal pathogens have been presented that could be studied in clinical settings with the goal of decreasing the need for systemic or prolonged antifungal treatments that may result in treatment failure or resistance.

Challenges in the Polyene- and Azole-Based Pharmacotherapy of Ocular Fungal Infections

Polyenes and azoles constitute 2 major drug classes in the antifungal armamentarium used to treat fungal infections of the eye such as fungal keratitis, endophthalmitis, conjunctivitis, and blepharitis. These classes of drugs have come to occupy an important niche in ophthalmic antifungal therapy due to their broad spectrum of activity against a variety of filamentous and yeast-like fungi. Natamycin suspension (Natacyn^®), a polyene antifungal drug, is currently the only US FDA-approved formulation for treating ophthalmic fungal infections, whereas the other polyene and azole antifungals such as amphotericin B, fluconazole, itraconazole, ketoconazole, miconazole, voriconazole, and posaconazole are routinely used off-label in the clinical setting. Despite potent antifungal activity, the clinical utility of these agents in ophthalmic infections has been challenged by their physicochemical properties, the unique ocular anatomy and physiology, selective antifungal activity, ocular and systemic toxicity, emergence of resistance and cross-resistance, and absence of reliable techniques for developing a robust in vitro-in vivo correlation. This review discusses the aforementioned challenges and the common approaches undertaken to circumnavigate the difficulties associated with the polyene- and azole-based pharmacotherapy of ophthalmic fungal infections.

The positive benefit of Lactobacillus paracasei NCC2461 ST11 in healthy volunteers with moderate to severe dandruff

Dandruff is a common persistent, relapsing inflammatory condition affecting the scalp. An imbalanced proportion of the major bacterial and fungal populations colonising the scalp, a skin barrier dysfunction, and hyperseborrhoea are three main etiological factors of dandruff. The efficacy of Lactobacillus paracasei NCC 2461 ST11 (ST11) to manage dandruff and to restore a balanced scalp microbiome was assessed. Sixty healthy male volunteers aged 18 to 60 years with moderate to severe dandruff consumed on a daily basis a sachet containing ST11 (1×109 cfu) or a placebo for 56 days. Clinical efficacy (free and adherent dandruff, erythema, scalp seborrhoea, global clinical score), subject self-assessments, safety reporting as well as scalp microbiota assessments were performed every two weeks (day 1, 15, 29, 43, 57 and 64/follow-up). Free and adherent dandruff, erythema and the global clinical score improved significantly (all P<0.05) over time in the ST11 group and as compared to the placebo when day 57 was compared to day 1. Self-assessments paralleled these findings. ST11 enhanced restoring the scalp microbiota after 56 days of supplementation when compared to the placebo. No adverse events were reported. Regular intake of ST11 over 56 days is safe and reduces significantly the severity of signs and symptoms of moderate to severe dandruff. Its efficacy is potentially due to its positive impact on the skin barrier and skin immune system.

Meristem Plant Cells as a Sustainable Source of Redox Actives for Skin Rejuvenation

Recently, aggressive advertisement claimed a “magic role” for plant stem cells in human skin rejuvenation. This review aims to shed light on the scientific background suggesting feasibility of using plant cells as a basis of anti-age cosmetics. When meristem cell cultures obtained from medicinal plants are exposed to appropriate elicitors/stressors (ultraviolet, ultrasound ultraviolet (UV), ultrasonic waves, microbial/insect metabolites, heavy metals, organic toxins, nutrient deprivation, etc.), a protective/adaptive response initiates the biosynthesis of secondary metabolites. Highly bioavailable and biocompatible to human cells, low-molecular weight plant secondary metabolites share structural/functional similarities with human non-protein regulatory hormones, neurotransmitters, pigments, polyamines, amino-/fatty acids. Their redox-regulated biosynthesis triggers in turn plant cell antioxidant and detoxification molecular mechanisms resembling human cell pathways. Easily isolated in relatively large quantities from contaminant-free cell cultures, plant metabolites target skin ageing mechanisms, above all redox imbalance. Perfect modulators of cutaneous oxidative state via direct/indirect antioxidant action, free radical scavenging, UV protection, and transition-metal chelation, they are ideal candidates to restore photochemical/redox/immune/metabolic barriers, gradually deteriorating in the ageing skin. The industrial production of plant meristem cell metabolites is toxicologically and ecologically sustainable for fully “biological” anti-age cosmetics.

Commercial Essential Oils as Potential Antimicrobials to Treat Skin Diseases

Essential oils are one of the most notorious natural products used for medical purposes. Combined with their popular use in dermatology, their availability, and the development of antimicrobial resistance, commercial essential oils are often an option for therapy. At least 90 essential oils can be identified as being recommended for dermatological use, with at least 1500 combinations. This review explores the fundamental knowledge available on the antimicrobial properties against pathogens responsible for dermatological infections and compares the scientific evidence to what is recommended for use in common layman's literature. Also included is a review of combinations with other essential oils and antimicrobials. The minimum inhibitory concentration dilution method is the preferred means of determining antimicrobial activity. While dermatological skin pathogens such as Staphylococcus aureus have been well studied, other pathogens such as Streptococcus pyogenes, Propionibacterium acnes, Haemophilus influenzae, and Brevibacterium species have been sorely neglected. Combination studies incorporating oil blends, as well as interactions with conventional antimicrobials, have shown that mostly synergy is reported. Very few viral studies of relevance to the skin have been made. Encouragement is made for further research into essential oil combinations with other essential oils, antimicrobials, and carrier oils.

Topical Treatment of Facial Seborrheic Dermatitis: A Systematic Review

BACKGROUND

Facial seborrheic dermatitis (SD), a chronic inflammatory skin condition, can impact quality of life, and relapses can be frequent. Three broad categories of agents are used to treat SD: antifungal agents, keratolytics, and corticosteroids. Topical therapies are the first line of defense in treating this condition.

OBJECTIVE

Our objective was to critically review the published literature on topical treatments for facial SD.

METHODS

We searched PubMed, Scopus, Clinicaltrials.gov, MEDLINE, Embase, and Cochrane library databases for original clinical studies evaluating topical treatments for SD. We then conducted both a critical analysis of the selected studies by grading the evidence and a qualitative comparison of results among and within studies.

RESULTS

A total of 32 studies were eligible for inclusion, encompassing 18 topical treatments for facial SD. Pimecrolimus, the focus of seven of the 32 eligible studies, was the most commonly studied topical treatment.

CONCLUSION

Promiseb^®, desonide, mometasone furoate, and pimecrolimus were found to be effective topical treatments for facial SD, as they had the lowest recurrence rate, highest clearance rate, and the lowest severity scores (e.g., erythema, scaling, and pruritus), respectively. Ciclopirox olamine, ketoconazole, lithium (gluconate and succinate), and tacrolimus are also strongly recommended (level A recommendations) topical treatments for facial SD, as they are consistently effective across high-quality trials (randomized controlled trials).

Maintenance Therapy of Facial Seborrheic Dermatitis with 0.1% Tacrolimus Ointment

BACKGROUND

Topical calcineurin inhibitors (TCIs) have been successfully used to treat seborrheic dermatitis (SD) patients. Meanwhile, treatment of atopic dermatitis (AD) with low-dose, intermittent TCI has been proved to reduce disease flare-ups. This regimen is known as a maintenance treatment.

OBJECTIVE

The aim of this trial was to investigate the efficacy and tolerability of a maintenance treatment with tacrolimus ointment in patients with facial SD.

METHODS

During the initial stabilization period, patients with facial SD or AD applied 0.1% tacrolimus ointment twice daily for up to 4 weeks. Clinical measurements were evaluated on either in the whole face or on separate facial regions. When an investigator global assessment score 1 was achieved, the patient applied tacrolimus twice weekly for 20 weeks. We also compared our results with recent published data of placebo controlled study to allow an estimation of the placebo effect.

RESULTS

The time to the first relapse during phase II was similar in both groups otherwise significantly longer than the placebo group. The recurrence-free curves of two groups were not significantly different from each other; otherwise the curve of the placebo group was significantly different. There were no significant differences between the 2 groups in the number of DEs, and treatment days for disease exacerbations (DEs). The adverse event profile was also similar between the 2 groups. During the 20 weeks of treatment, the study population tolerated tacrolimus ointment well.

CONCLUSION

The results of this study suggest that maintenance treatment with tacrolimus may be effective in preventing the occurrence of facial SD exacerbations.

Topical antifungals for seborrhoeic dermatitis

BACKGROUND

Seborrhoeic dermatitis is a chronic inflammatory skin condition that is distributed worldwide. It commonly affects the scalp, face and flexures of the body. Treatment options include antifungal drugs, steroids, calcineurin inhibitors, keratolytic agents and phototherapy.

OBJECTIVES

To assess the effects of antifungal agents for seborrhoeic dermatitis of the face and scalp in adolescents and adults.A secondary objective is to assess whether the same interventions are effective in the management of seborrhoeic dermatitis in patients with HIV/AIDS.

SEARCH METHODS

We searched the following databases up to December 2014: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 11), MEDLINE (from 1946), EMBASE (from 1974) and Latin American Caribbean Health Sciences Literature (LILACS) (from 1982). We also searched trials registries and checked the bibliographies of published studies for further trials.

SELECTION CRITERIA

Randomised controlled trials of topical antifungals used for treatment of seborrhoeic dermatitis in adolescents and adults, with primary outcome measures of complete clearance of symptoms and improved quality of life.

DATA COLLECTION AND ANALYSIS

Review author pairs independently assessed eligibility for inclusion, extracted study data and assessed risk of bias of included studies. We performed fixed-effect meta-analysis for studies with low statistical heterogeneity and used a random-effects model when heterogeneity was high.

MAIN RESULTS

We included 51 studies with 9052 participants. Of these, 45 trials assessed treatment outcomes at five weeks or less after commencement of treatment, and six trials assessed outcomes over a longer time frame. We believe that 24 trials had some form of conflict of interest, such as funding by pharmaceutical companies.Among the included studies were 12 ketoconazole trials (N = 3253), 11 ciclopirox trials (N = 3029), two lithium trials (N = 141), two bifonazole trials (N = 136) and one clotrimazole trial (N = 126) that compared the effectiveness of these treatments versus placebo or vehicle. Nine ketoconazole trials (N = 632) and one miconazole trial (N = 47) compared these treatments versus steroids. Fourteen studies (N = 1541) compared one antifungal versus another or compared different doses or schedules of administration of the same agent versus one another. KetoconazoleTopical ketoconazole 2% treatment showed a 31% lower risk of failed clearance of rashes compared with placebo (risk ratio (RR) 0.69, 95% confidence interval (CI) 0.59 to 0.81, eight studies, low-quality evidence) at four weeks of follow-up, but the effect on side effects was uncertain because evidence was of very low quality (RR 0.97, 95% CI 0.58 to 1.64, six studies); heterogeneity between studies was substantial (I² = 74%). The median proportion of those who did not have clearance in the placebo groups was 69%.Ketoconazole treatment resulted in a remission rate similar to that of steroids (RR 1.17, 95% CI 0.95 to 1.44, six studies, low-quality evidence), but occurrence of side effects was 44% lower in the ketoconazole group than in the steroid group (RR 0.56, 95% CI 0.32 to 0.96, eight studies, moderate-quality evidence).Ketoconozale yielded a similar remission failure rate as ciclopirox (RR 1.09, 95% CI 0.95 to 1.26, three studies, low-quality evidence). Most comparisons between ketoconazole and other antifungals were based on single studies that showed comparability of treatment effects. CiclopiroxCiclopirox 1% led to a lower failed remission rate than placebo at four weeks of follow-up (RR 0.79, 95% CI 0.67 to 0.94, eight studies, moderate-quality evidence) with similar rates of side effects (RR 0.9, 95% CI 0.72 to 1.11, four studies, moderate-quality evidence). Other antifungalsClotrimazole and miconazole efficacies were comparable with those of steroids on short-term assessment in single studies.Treatment effects on individual symptoms were less clear and were inconsistent, possibly because of difficulties encountered in measuring these symptoms.Evidence was insufficient to conclude that dose or mode of delivery influenced treatment outcome. Only one study reported on treatment compliance. No study assessed quality of life. One study assessed the maximum rash-free period but provided insufficient data for analysis. One small study in patients with HIV compared the effect of lithium versus placebo on seborrhoeic dermatitis of the face, but treatment outcomes were similar.

AUTHORS' CONCLUSIONS

Ketoconazole and ciclopirox are more effective than placebo, but limited evidence suggests that either of these agents is more effective than any other agent within the same class. Very few studies have assessed symptom clearance for longer periods than four weeks. Ketoconazole produced findings similar to those of steroids, but side effects were fewer. Treatment effect on overall quality of life remains unknown. Better outcome measures, studies of better quality and better reporting are all needed to improve the evidence base for antifungals for seborrhoeic dermatitis.

Honey in dermatology and skin care: a review

Honey is a bee-derived, supersaturated solution composed mainly of fructose and glucose, and containing proteins and amino acids, vitamins, enzymes, minerals, and other minor components. Historical records of honey skin uses date back to the earliest civilizations, showing that honey has been frequently used as a binder or vehicle, but also for its therapeutic virtues. Antimicrobial properties are pivotal in dermatological applications, owing to enzymatic H2 O2 release or the presence of active components, like methylglyoxal in manuka, while medical-grade honey is also available. Honey is particularly suitable as a dressing for wounds and burns and has also been included in treatments against pityriasis, tinea, seborrhea, dandruff, diaper dermatitis, psoriasis, hemorrhoids, and anal fissure. In cosmetic formulations, it exerts emollient, humectant, soothing, and hair conditioning effects, keeps the skin juvenile and retards wrinkle formation, regulates pH and prevents pathogen infections. Honey-based cosmetic products include lip ointments, cleansing milks, hydrating creams, after sun, tonic lotions, shampoos, and conditioners. The used amounts range between 1 and 10%, but concentrations up to 70% can be reached by mixing with oils, gel, and emulsifiers, or polymer entrapment. Intermediate-moisture, dried, and chemically modified honeys are also used. Mechanisms of action on skin cells are deeply conditioned by the botanical sources and include antioxidant activity, the induction of cytokines and matrix metalloproteinase expression, as well as epithelial-mesenchymal transition in wounded epidermis. Future achievements, throwing light on honey chemistry and pharmacological traits, will open the way to new therapeutic approaches and add considerable market value to the product.

Seborrheic scalp dermatitis: current concepts of its etiology, pathogenesis and therapy

The authors provide a review of current concepts of the epidemiology, etiology, pathogenesis and treatment principles for seborrheic scalp dermatitis. They also describe the results of multiple national and foreign studies confirming high clinical efficacy of ketoconazole 2% shampoo in the therapy of seborrheic dermatitis.

A review of applications of tea tree oil in dermatology

Tea tree oil (TTO) is an essential oil, steam-distilled from the Australian native plant, Melaleuca alternifolia. It has a minimum content of terpinen-4-ol and a maximum content of 1, 8-cineole. Terpinen-4-ol is a major TTO component which exhibits strong antimicrobial and anti-inflammatory properties. Tea tree oil exerts antioxidant activity and has been reported to have broad-spectrum antimicrobial activity against bacterial, viral, fungal, and protozoal infections affecting skin and mucosa. Several studies have suggested the uses of TTO for the treatment of acne vulgaris, seborrheic dermatitis, and chronic gingivitis. It also accelerates the wound healing process and exhibits anti-skin cancer activity. This review opens up new horizons for dermatologists in the use of this herbal agent.

Seborrheic dermatitis: a clinical practice snapshot

Seborrheic dermatitis is a chronic, recurring skin disorder that has no cure.Current clinical research has implicated Malassezia yeast in the etiology. Using a clear, concise clinical picture and a thorough patient history, even the novice NP can formulate an effective treatment plan.

Dandruff: the most commercially exploited skin disease

The article discuss in detail about the prevalence, pathophysiology, clinical manifestations of dandruff including the etio-pathology. The article also discusses in detail about various treatment methods available for dandruff. The status of dandruff being amphibious – a disease/disorder, and relatively less medical intervention is sought after for the treatment, dandruff is the most commercially exploited skin and scalp disorder/disease by personal care industries.

Pathogenic role of Demodex mites in blepharitis

PURPOSE OF REVIEW

To summarize the key literature and our research experience regarding Demodex infestation as a potential cause of ocular inflammatory diseases with a special emphasis on Demodex blepharitis.

RECENT FINDINGS

Two distinct Demodex species have been confirmed as a cause of blepharitis: Demodex folliculorum can cause anterior blepharitis associated with disorders of eyelashes, and D. brevis can cause posterior blepharitis with meibomian gland dysfunction and keratoconjunctivitis. Tea tree oil treatments with either 50% lid scrubs or 5% lid massages are effective in eradicating mites and reducing ocular surface inflammation.

SUMMARY

Demodex blepharitis is a common but overlooked external eye disease. The pathogenesis of Demodex blepharitis in eliciting ocular surface inflammation has been further clarified. The modified eyelash sampling and counting method makes it easier and more accurate to diagnose Demodex infestation. Tea tree oil shows promising potential to treat Demodex blepharitis by reducing Demodex counts with additional antibacterial, antifungal, and anti-inflammatory actions.

An open-label, single-center pilot study to determine the antifungal activity of a new nonsteroidal cream (Promiseb Topical Cream) after 7 days of use in healthy volunteers

Topical corticosteroids are effective for the treatment of seborrheic dermatitis. The duration of treatment with mid- to high-potency formulations is limited by the well-known side effects associated with their long-term use; further, topical corticosteroids treat only the inflammation associated with the disease. This study assessed the antifungal activity of a new corticosteroid-free cream against Malassezia spp, which may be an important pathogenic factor in seborrheic dermatitis. This was a single-center, bilateral, open-label pilot study in 10 healthy volunteers. The nonsteroidal cream was applied twice daily to a designated target area on the chest for 7 days, and the number of colony-forming units of Malassezia spp taken by tape stripping after 7 days was compared with baseline. The percentage reduction from baseline to day 7 in the number of colony-forming units of Malassezia spp was 94% on the treated side versus 49% on the untreated side (P = .03). This pilot study shows the nonsteroidal topical cream has antifungal activities. Further exploration into its potential as a therapeutic alternative for seborrheic dermatitis is warranted.

Correlation between ocular Demodex infestation and serum immunoreactivity to Bacillus proteins in patients with Facial rosacea

PURPOSE

To investigate correlation between ocular Demodex infestation and serum.

DESIGN

A prospective study to correlate clinical findings with laboratory data.

PARTICIPANTS

We consecutively enrolled 59 patients: 34 men and 25 women with a mean age of 60.4+/-17.6 years (range, 17-93).

METHODS

Demodex counting was performed based on lash sampling. Serum immunoreactivity to two 62-kDa and 83-kDa proteins derived from B oleronius was determined by Western blot analysis. Facial rosacea, lid margin, and ocular surface inflammation were documented by photography and graded in a masked fashion.

MAIN OUTCOME MEASURES

Statistical significance based on correlative analyses of clinical and laboratory data.

RESULTS

These 59 patients were age matched, but not gender matched, regarding serum immunoreactivity, ocular Demodex infestation, or facial rosacea. There was a significant correlation between serum immunoreactivity and facial rosacea (P = 0.009), lid margin inflammation (P = 0.040), and ocular Demodex infestation (P = 0.048), but not inferior bulbar conjunctival inflammation (P = 0.573). The Demodex count was significantly higher in patients with positive facial rosacea (6.6+/-9.0 vs. 1.9+/-2.2; P = 0.014). There was a significant correlation of facial rosacea with lid margin inflammation (P = 0.016), but not with inferior bulbar conjunctival inflammation (P = 0.728). Ocular Demodex infestation was less prevalent in patients with aqueous tear-deficiency dry eye than those without (7/38 vs. 12/21; P = 0.002).

CONCLUSIONS

The strong correlation provides a better understanding of comorbidity between Demodex mites and their symbiotic B oleronius in facial rosacea and blepharitis. Treatments directed to both warrant future investigation.

Is Demodex folliculorum an aetiological factor in seborrhoeic dermatitis?

BACKGROUND

Seborrhoeic dermatitis (SD) is a common inflammatory skin disease for which no single cause has been found, although many factors have been implicated. The mite Demodex folliculorum (DF) is most commonly seen in the pilosebaceous unit in humans. SD is located in areas that are rich in sebaceous glands, which are also preferred by DF.

AIMS

To compare the number of DF parasites in patients with clinical SD and in healthy controls, and to investigate any possible relationship between the number of DF mites and the presence of SD.

METHODS

The study comprised 38 patients with SD and 38 healthy controls. Standard random and lesion-specific sampling was performed in the group of patients with SD, whereas standard random sampling only was performed for controls.

RESULTS

Demodex folliculorum sampling was positive in 19 patients (50%) and 5 controls (13.1%). Mean DF density was 8.16 +/- 10.1/cm(2) (range 0-40) and 1.03 +/- 2.17/cm(2) (1-7) in patient and control groups, respectively. The differences between groups for DF positivity and mean DF density were significant (P = 0.001 for each). DF was found in 13 lesional areas in the patient group, but in only 5 areas in the control group (P = 0.031).

CONCLUSIONS

The number of DF mites was significantly higher in both lesional and nonlesional areas of patients with SD. This suggests that, when other aetiological causes are excluded, DF may have either direct or indirect role in the aetiology of SD.

Diagnosis and management of common dermatoses in children: atopic, seborrheic, and contact dermatitis

Atopic, seborrheic, and contact dermatitis can significantly reduce the quality of life of patients and their families. Although differing in specific aspects of their epidemiology, etiology, and pathobiology, all 3 dermatoses are common in the pediatric population, and they share a common treatment approach. Although effective and widely used to manage exacerbations of pediatric dermatitis, the use of topical corticosteroid remains a concern for some physicians and parents because of its potential for systemic absorption and adverse events associated with prolonged use. Newer additions to the dermatitis treatment algorithm, such as the topical calcineurin inhibitors, may provide an effective steroid-sparing treatment option. Adjuvant treatments, such as antihistamines, antifungals, and antibiotics, also can provide benefit in appropriate circumstances. As there is no cure for dermatitis, a comprehensive, multipronged management strategy of preventive measures, such as trigger avoidance and periodic pharmacologic treatment, will provide patients and caregivers with the best opportunity to successfully control the disease.

Molecular Analysis of Malassezia Microflora in Seborrheic Dermatitis Patients: Comparison with Other Diseases and Healthy Subjects

Malassezia species colonize the skin of normal and various pathological conditions including pityriasis versicolor (PV), seborrhoeic dermatitis (SD) and atopic dermatitis (AD). To elucidate the pathogenic role of Malassezia species in SD, Malassezia microflora of 31 Japanese SD patients was analyzed using a PCR-based, culture-independent method. Nested PCR assay using the primers in the rRNA gene indicated that the major Malassezia species in SD were M. globosa and M. restricta, found in 93 and 74% of the patients, respectively. The detection rate and number of each species varied similarly in SD, PV and healthy subjects (HSs), whereas AD showed higher values. Real-time PCR assay showed that the lesional skin harbored approximately three times the population of genus Malassezia found in nonlesional skin (P<0.05), and that M. restricta is a significantly more common species than M. globosa in SD (P<0.005). Genotypic analysis of the rRNA gene showed that the M. globosa and M. restricta from SD patients fell into specific clusters, and could be distinguished from those collected from HSs, but not from those colleted from AD patients. Our results indicate that certain strains of M. restricta occur in the lesional skin of SD patients.

Results of a randomized, double-blind, vehicle-controlled efficacy trial of pimecrolimus cream 1% for the treatment of moderate to severe facial seborrheic dermatitis

BACKGROUND

Seborrheic dermatitis is commonly treated with anti-inflammatory products, including topical corticosteroids. Pimecrolimus cream 1% also exerts anti-inflammatory activity by inhibiting T-cell cytokine production.

OBJECTIVE

We sought to compare the efficacy and safety of twice-daily pimecrolimus for treatment of moderate to severe facial seborrheic dermatitis.

METHODS

This double-blind, vehicle-controlled, 4-week trial randomized patients with seborrheic dermatitis to pimecrolimus or vehicle (1:1). Clinical assessments (erythema [0-3] and scaling [0-3] combined for a total area score [0-6]) were performed at weeks 0, 2, and 4. Inclusion criteria included total area score 4 or greater and erythema 2 or greater. The prespecified primary variable, change from baseline in total area score at week 4, was analyzed using a two-sample t test for intent-to-treat and per protocol populations.

RESULTS

In all, 96 adults of mean age 59.6 years, 88.5% male, were randomized (n = 47 pimecrolimus; 49 vehicle). At week 4, the mean change from baseline in total area score was 3.7 versus 3.3 for pimecrolimus and vehicle groups, respectively (intent-to-treat: P = .1913; 95% confidence interval (CI) for difference [-0.195, 0.961]). Per protocol analysis (n = 41 pimecrolimus; 46 vehicle) indicated a significant difference between groups (mean change 3.9 pimecrolimus vs 3.2 vehicle; P = .0156; CI [0.129, 1.197]). The superiority of pimecrolimus was observed as early as week 2 (intent-to-treat: P = .0062; CI [0.132, 0.777]; per protocol: P = .0012; CI [0.410, 1.593]). No drug-related serious adverse events occurred. The most frequent drug-related adverse events were local, mild, and transient (pimecrolimus = 26%; vehicle = 12%).

LIMITATIONS

Generalizability is limited by the elderly male study population.

CONCLUSION

This study suggests that pimecrolimus cream 1% is an effective and well-tolerated treatment for moderate to severe facial seborrheic dermatitis.

Corneal manifestations of ocular demodex infestation

PURPOSE

To report the corneal manifestations in eyes with Demodex infestation of the eyelids.

DESIGN

Noncomparative, interventional case series.

METHODS

This retrospective review included six patients with Demodex blepharitis who also exhibited corneal abnormalities, which led to suspicion of limbal stem cell deficiency in three cases. All patients received weekly lid scrubs with 50% tea tree oil and a daily lid scrubs with tea tree shampoo for a minimum of six weeks. Improvement of symptoms and corneal and conjunctival signs were evaluated.

RESULTS

All six patients exhibited ocular irritation and conjunctival inflammation, while meibomian gland dysfunction (n = 5), rosacea (n = 4), and decreased vision (n = 3) also were noted despite prior treatments with oral tetracycline, topical steroids with antibiotics, and lid scrub with baby shampoo. These patients were proven to have Demodex folliculorum (n = 6) and Demodex brevis (n = 3) by microscopic examination of epilated lashes. Their corneal manifestation included superficial corneal vascularization (six eyes of five cases), marginal corneal infiltration (two eyes of two cases), phlyctenule-like lesion (one eye of one case), superficial corneal opacity (two eyes of two cases), and nodular corneal scar (two eyes of two cases). After treatment, the Demodex count was reduced from 6.8 +/- 2.8 to 1 +/- 0.9 (standard deviation; P = .001). All patients showed dramatic resolution of ocular irritation, conjunctival inflammation, and all inflammatory, but not scarred, corneal signs; three patients showed improved vision.

CONCLUSIONS

A variety of corneal pathologic features together with conjunctival inflammation, commonly noted in rosacea, can be found in patients with Demodex infestation of the eyelids. When conventional treatments for rosacea fail, one may consider lid scrub with tea tree oil to eradicate mites as a new treatment.

Inhibitory or scavenging action of ketoconazole and ciclopiroxolamine against reactive oxygen species released by primed inflammatory cells

BACKGROUND

Reactive oxygen species (ROS) released from inflammatory cells constitute one of the critical causative factors in inflammatory skin diseases such as seborrhoeic dermatitis and atopic dermatitis.

OBJECTIVES

To investigate inhibitory effects of ketoconazole (KCZ) and ciclopiroxolamine (CPO), both of which have been used for the treatment of seborrhoeic dermatitis, on ROS released from inflammatory cells.

METHODS

The methyl-Cypridina-luciferin analogue-dependent chemiluminescence method was employed for the detection of ROS production by phorbol 12-myristate 13-acetate (PMA)-stimulated inflammatory cells. Moreover, the radical scavenging activities of both agents were examined by using a hypoxanthine-xanthine oxidase system and the stable radical 1,1-diphenyl-2-picrylhydrazyl (DPPH). NADPH oxidase activity was determined in particulate (membrane) fractions prepared from PMA-stimulated RAW 264 x 7 cells, a macrophage-like cell line.

RESULTS

Both of these antifungal agents inhibited PMA-stimulated ROS production. However, only CPO significantly scavenged both ROS generated by the hypoxanthine-xanthine oxidase system and DPPH, and the scavenging activity of CPO seemed to act on ROS other than superoxide anions. Although KCZ inhibited PMA-stimulated ROS production, it did not show radical-scavenging activities. The inhibition of ROS production by KCZ is probably attributable to the inhibition of NADPH oxidase activity.

CONCLUSIONS

The mechanism of the inhibitory action of KCZ against PMA-stimulated ROS production is distinct from that of CPO. Knowledge of the inhibitory or scavenging effects of both antifungal agents on ROS released from inflammatory cells may be useful in developing a therapeutic strategy for dermatitis.

Efficacy of oral fluconazole in the treatment of seborrheic dermatitis: a placebo-controlled study

BACKGROUND

Seborrheic dermatitis (SD) is a common, chronic dermatosis. Although the pathogenetic mechanisms of SD are not clear, Malassezia spp. yeasts are known to cause the disease. Previous studies have shown that topical and systemic antifungals provide clinical benefit.

OBJECTIVE

To evaluate the safety and efficacy of short-term oral fluconazole in patients with SD.

METHODS

Sixty-three patients with mild-to-moderate SD were randomly allocated to receive either oral fluconazole 300 mg in a single dose per week or placebo, for 2 weeks. Twenty-seven patients taking fluconazole and 23 patients taking placebo completed the study and were analyzed. The SD area severity index (SDASI) score and the patient's subjective assessment of pruritus and burning sensation were evaluated before and after treatment. Both the investigator and the patients were blinded to treatment.

RESULTS

A statistically significant improvement in SDASI score after treatment compared with baseline was obtained with fluconazole (p=0.01) but not with placebo. However, the difference between the treatment groups was not statistically significant (p>0.05). Subjective improvements in symptoms, such as pruritus and burning sensation, were observed in both groups but no statistically significant differences versus baseline were seen.

CONCLUSION

The results of this study indicate that fluconazole provides marginal and statistically insignificant benefit for the therapy of SD. However, larger studies using different dosages and/or durations of fluconazole therapy may provide a rationale for systemic use of fluconazole in SD.