Access to bacteriophage therapy: discouraging experiences from the human cell and tissue legal framework

Cultures of human epithelial cells (keratinocytes) are used as an additional surgical tool to treat critically burnt patients. Initially, the production environment of keratinocyte grafts was regulated exclusively by national regulations. In 2004, the European Tissues and Cells Directive 2004/23/EC (transposed into Belgian Law) imposed requirements that resulted in increased production costs and no significant increase in quality and/or safety. In 2007, Europe published Regulation (EC) No. 1394/2007 on Advanced Therapy Medicinal Products. Overnight, cultured keratinocytes became (arguably) 'Advanced' Therapy Medicinal Products to be produced as human medicinal products. The practical impact of these amendments was (and still is) considerable. A similar development appears imminent in bacteriophage therapy. Bacteriophages are bacterial viruses that can be used for tackling the problem of bacterial resistance development to antibiotics. Therapeutic natural bacteriophages have been in clinical use for almost 100 years. Regulators today are framing the (re-)introduction of (natural) bacteriophage therapy into 'modern western' medicine as biological medicinal products, also subject to stringent regulatory medicinal products requirements. In this paper, we look back on a century of bacteriophage therapy to make the case that therapeutic natural bacteriophages should not be classified under the medicinal product regulatory frames as they exist today. It is our call to authorities to not repeat the mistake of the past.

LEKTI-1 in sickness and in health

The stratum corneum (SC) is a biosensor that mediates responses to a variety of exogenous insults through various signalling mechanisms, including the activation of SC serine proteases (SP) kallikrein cascade. The SPINK5 gene encodes an SP inhibitor, the lympho-epithelial-Kazal-type-1 inhibitor (LEKTI-1), which in turn will buffer the excess of SP cascade initiation, key in the maintenance of permeability barrier homeostasis. We demonstrate that LEKTI processing can occur within the SC after secretion from stratum granulosum keratinocytes at least partially by klk7, an SC-specific chymotryptic SP. Unlike the recently described LEKTI-2, neither recombinant full-length LEKTI-1 nor recombinant LEKTI-1 fragments exhibit antimicrobial activity. Finally, we discuss the pathophysiological implications of LEKTI-1 in skin biology as well as its contribution to the pathogenesis of Netherton Syndrome and its potential involvement in atopic dermatitis.

Alexithymia in patients with alopecia areata: educational background much more important than traumatic events

BACKGROUND

Recent studies suggest a higher prevalence of alexithymia in patients with alopecia areata (AA). Some authors link alexithymia with the presence of early traumatic events, such as dysfunctional parent-child relationships. However, until today, no studies have been carried out on the association of alexithymia and early traumatic events in AA patients.

OBJECTIVE

The primary aim of this study was to explore if an association exists between the presence of traumatic childhood experiences and alexithymia in AA patients. A secondary aim was to confirm earlier observations indicating that the occurrence and/or degree of alexithymia is higher in patients with AA compared with individuals from the general population.

METHODS

We enrolled 90 patients with AA. Data on alexithymia and traumatic events were collected with two self-report questionnaires: the Toronto Alexithymia Scale-20 and the Traumatic Experiences Checklist. These data were compared with data obtained from control patients without AA randomly selected from patients presenting for dermatological surgery.

RESULTS

In adult AA patients, we found no evidence for a significant association between Toronto Alexithymia Scale (TAS) scores and emotional neglect or childhood traumatic experiences. We found a significant association with educational level, higher levels of education being associated with lower TAS-20 scores (P = 0.002). The mean TAS-20 score of 51.22 (SD 11.90) in our adult AA patient group was significantly higher compared with control patients from the same setting (44.00, SD 10.33, P < 0.001).

CONCLUSION

In adult AA patients, higher levels of education are significantly associated with lower alexithymia scores. Somewhat unexpectedly, we found no association between alexithymia score and emotional neglect or childhood traumatic experiences. Our results also confirm that alexithymia scores are significantly higher in adult patient with AA compared with control patients.

Seasonal effects on the nasolabial skin condition

In the present work, nasolabial skin condition and the influence of seasonal changes during autumn and winter were studied in 16 healthy female volunteers. Apart from visual scoring of erythema and skin scaliness, transepidermal water loss (TEWL), skin hydration, apparent skin pH, skin colour and skin desquamation were biophysically measured. The study results showed that nasolabial TEWL was significantly higher during wintertime than in autumn. Also skin colour measurements and squamometry scorings revealed higher values, indicating a more reddish and scaly nasolabial skin during winter compared to autumn. Results from tape stripping and skin surface lipid analysis by high-performance thin-layer chromatography demonstrated significant differences for triglycerides and cholesterol esters, indicating a functionally inferior hydrolipidic layer during the winter season.

Trichothiodystrophy-like hair abnormalities in a child with keratitis ichthyosis deafness syndrome

Keratitis ichthyosis deafness syndrome is a rare congenital ectodermal disorder. It appears to be genetically heterogeneous and may be caused by mutations in the connexin 26 (Cx26) gene (GJB2) or in the connexin 30 gene. It is characterized by the association of ichthyosis-like skin lesions, hearing loss, and vascularizing keratitis. We report the clinical and molecular findings in a 5-year-old girl with keratitis ichthyosis deafness syndrome. DNA sequencing in our patient revealed a p.Ser17Phe mutation in GJB2. Besides the typical clinical features of keratitis ichthyosis deafness syndrome, a peculiar intriguing finding not previously described in the literature in this condition was that polarizing light microscopy of the scalp hair in our patient revealed striking bright and dark bands as seen in trichothiodystrophy. Amino acid analysis of the hair sample also disclosed a reduced cysteine index. We emphasize that it would be of great benefit to examine hair shafts in other patients with keratitis ichthyosis deafness syndrome for trichothiodystrophy-like abnormalities.

Oral R115866 in the treatment of moderate to severe facial acne vulgaris: an exploratory study

BACKGROUND

R115866 (Rambazole; Barrier Therapeutics NV, Geel, Belgium), a new-generation retinoic acid metabolism-blocking agent, is a nonretinoid compound enhancing intracellularly the endogenous levels of all-trans-retinoic acid by blocking its catabolism. By virtue of this property, and the proven positive effects of retinoids in the treatment of acne, R115866 could potentially be a useful drug for acne.

OBJECTIVES

To explore the efficacy, safety and tolerability of systemic R115866 in male patients with moderate to severe facial acne vulgaris (at least 15 papules and/or pustules and at least two nodulocystic lesions).

METHODS

In this exploratory trial, 17 patients were treated with oral R115866 1 mg once daily for 12 weeks, followed by a 4-week treatment-free period.

RESULTS

At the end of treatment (week 12, n = 16) a mean reduction in inflammatory lesion count of 77.4% (P < 0.001), in noninflammatory lesion count of 58.3% (P < 0.001) and in total lesion count of 76.0% (P < 0.001) was observed as compared with baseline. All lesion counts were significantly reduced from week 4 onwards. Mild side-effects were reported occasionally.

CONCLUSIONS

The current data indicate that treatment with oral R115866 1 mg once daily for 12 weeks in patients with moderate to severe facial acne vulgaris is efficacious and well tolerated and merits further investigation.

Distinct phenotypic changes between the superficial and deep component of giant congenital melanocytic naevi: a rationale for curettage

BACKGROUND

Giant congenital melanocytic naevi (GCMN) convey a 14-fold increased melanoma risk. In contrast, medium congenital melanocytic naevi (MCMN) are rarely associated with malignant transformation. Management of patients with GCMN is challenging and there is no consensus on the most appropriate strategy for treating these patients.

OBJECTIVES

To provide a rationale for performing curettage of GCMN in the neonatal period in order to reduce the risk of malignant transformation to melanoma.

METHODS

Twenty-six infants with GCMN who underwent biopsies before excisional surgery (n = 7) or curettage (n = 19) during the past 14 years (Academic Hospital, Vrije Universiteit Brussel) and 10 MCMN patients who underwent excision biopsies (Radboud University Nijmegen Medical Centre) were included in this study. Using these biopsies, we performed genetic and detailed immunohistochemical evaluations of changes that are associated with malignant transformation. Variables of interest included melanoma-associated BRAF mutations, proliferative activity, vascularity, cellular context and extracellular matrix architecture.

RESULTS

GCMN and MCMN did not show oncogenic BRAF mutation and displayed similar features with respect to the amount of nonmelanocytic cells within the naevus and matrix architecture. Naevus cells in the superficial component of the GCMN, however, were more proliferative, and this component was more vascular compared with its deep component and with MCMN. In this study, none of the 19 newborn patients who underwent curettage developed a melanoma within a mean follow-up time of 7 years.

CONCLUSIONS

The data presented here support the idea that curettage of GCMN in neonates has the potential for lowering the risk of developing cutaneous melanoma by not only obtaining an important numerical reduction of naevus cells but also removing the 'active' melanocytes.

Analysis of epidermal lipids of the healthy human skin: factors affecting the design of a control population

The intervariability of studies on the lipids of human epidermis and stratum corneum is high because of the different origin of the skin samples and the variety of extraction methods used. In the present work, a high-performance thin-layer chromatographic technique has been used to study the parameters age, sex, and anatomical site for their effects on the lipid profiles recovered from healthy epidermal skin biopsy specimens. It was found that sex-related differences were seen at the level of the total ceramide concentration. Observed decreases in lipid concentration, due to ageing, depended on the anatomical site. Therefore, these variables should be controlled in a reproducible and standardized way in order to be able to study the direct relationship between skin condition and barrier lipid composition. Only when this relation is established, results of topical treatment can be scientifically evaluated.

High prevalence of foot diseases in Europe: results of the Achilles Project

OBJECTIVE

To provide an insight into the prevalence of foot disease in Europe, and to include an assessment of the prevalence of predisposing factors and their correlation with foot disease.

DESIGN

Large population-based survey conducted in 16 European countries.

SETTING

The project consisted of two parts (study I and study II), in which all patients presenting to general practitioners and dermatologists over a defined time period were invited to participate. Patients. In study I, 70,497 patients presenting to dermatologists or general practitioners were recruited, and in study II 19,588 patients presenting to dermatologists were recruited.

MAIN OUTCOME MEASURE

The feet of all participants were examined for signs of foot disease. The assessors also recorded relevant details such as the age and sex of patients, and the presence of predisposing factors for foot disease. In addition, patients in study II were offered a free mycological examination of the toenails and skin on the feet.

RESULTS

In study I, 57.0% of patients had at least one foot disease. In study II, 61.3% had at least one foot disease. The proportions of patients with fungal foot disease and non-fungal foot disease in study I were 34.9% and 38.4%, respectively, and in study II were 40.6% and 41.7%, respectively. Orthopedic conditions and metatarsal corns were the most frequently reported non-fungal foot diseases, and onychomycosis and tinea pedis were the most frequently observed fungal infections.

CONCLUSIONS

This large-scale survey suggests that the prevalence of fungal and non-fungal foot disease is higher than previously estimated.

The treatment of basal skin carcinomas in two sisters with xeroderma pigmentosum

Xeroderma pigmentosum (XP) is a rare autosomal recessive disorder that causes defects in the DNA repair system. It is characterized by a marked sensitivity to sunlight, and sufferers develop serious sunburns with onset of poikilodermia in the light-exposed skin. Squamous cell carcinomas, basal cell carcinomas (BCCs) and malignant melanomas appear in childhood. Two sisters with XP presented with previously treated facial BCCs. They were treated with imiquimod 5% cream three times weekly, one for 6 weeks and the other for 10 weeks. Although both sisters temporarily discontinued treatment due to severe erythema and erosion, successful long-term clearance was observed with no recurrences in both cases.

Repair of acetone- and sodium lauryl sulphate-damaged human skin barrier function using topically applied emulsions containing barrier lipids

BACKGROUND

It is generally acknowledged that well-formulated moisturizing skin care products can restore disturbed barrier function that can be assessed by transepidermal water loss (TEWL) measurements. When ceramides and/or other barrier lipids are incorporated, it is, however, not always clearly demonstrated which ingredients of the formulation exert the beneficial effects.

OBJECTIVES

In this study the effects of topically applied ceramide-containing mixtures on the barrier repair of sodium lauryl sulphate (SLS)- and acetone-induced skin damage have been studied in human volunteers. TEWL and stratum corneum hydration measurements were carried out. The emulsions applied contained either a mixture of two types of ceramides, CerIII and CerIIIB (emulsion 1) or a complete mixture of ceramides III, IIIB and VI together with phytosphingosine, cholesterol and the free fatty acid linoleic acid (emulsion 2).

RESULTS

After SLS damage, it was observed that barrier recovery was significantly accelerated by topical application (14 days, 2 x/d) of emulsion 2 compared with the results obtained with emulsion 1. Corneometrical results were not relevant due to the occurrence of scaly fissured skin, failing to provide a good skin/probe contact. Although no effect on TEWL could be observed, the improvement of skin hydration after acetone treatment and a single application of the emulsions, was significantly more positive for emulsion 2 than for emulsion 1.

CONCLUSIONS

The investigative methods used in this study show that ceramides combined with other skin lipids can improve barrier repair after damage.

Efficacy of topical corticosteroids in nickel-induced contact allergy

In this study we used the nickel contact allergy patch (CAP) test to investigate the effect of topical corticosteroids on allergic contact dermatitis (ACD). On day 1, three CAP tests were applied for 48 h on the forearms of 20 female volunteers with a known nickel ACD. CAP of the right forearm contained 5% nickel, and of the left forearm physiological saline. Clinical scoring, transepidermal water loss and skin hydration were measured on day 1 before CAP application, on day 4 (0, 2 and 6 h) after ACD and from days 5 to 8 (0 h). A topical corticosteroid and its vehicle were applied twice daily starting from day 4 on two ACD sites. Transepidermal water loss values were significantly decreased on the topical-corticosteroid-treated sites in the early phase of ACD (day 4, 6 h after the first application) while clinical efficacy showed significant improvement on days 7 and 8. The vehicle was found to improve skin hydration only on day 8. In conclusion the topical corticosteroid improved the skin barrier function in the early inflammatory phase of ACD (day 4, 6 h). The lack of improvement in transepidermal water loss in the later phase of ACD might be accounted for by the secondary effects of the corticosteroid on proliferation and differentiation of keratinocytes.

Combination therapy improves the recovery of the skin barrier function: an experimental model using a contact allergy patch test combined with TEWL measurements

BACKGROUND

Nickel (Ni) allergic contact dermatitis (ACD) alters the skin barrier.

OBJECTIVE

Our aim was to compare the efficacy of combination therapies on ACD, using a topical corticosteroid and a corneotherapy agent (barrier cream), with that of a single therapy with corticosteroids.

METHODS

On day 1, 3 Ni test patches were applied on each forearm of 14 Ni-patch-test-positive females. Four contained 5% Ni and 2 physiological saline. Either topical corticosteroid or barrier cream were matched with the combination of both products on 3 of the 4 Ni ACD. The fourth was not treated. Clinical scoring, transepidermal water loss (TEWL) and stratum corneum (SC) capacitance were measured before (day 1) and after (days 4-8) ACD.

RESULTS

The combination therapy showed a significant decrease in TEWL values and an increase in SC capacitance.

CONCLUSION

Combining a topical corticosteroid with corneotherapy agents prevents the delay in the healing process of skin barrier disruption due to ACD.

Squamometry as a screening method for the evaluation of hydrating products

BACKGROUND/AIMS

Squamometry is a combination of sampling corneocytes by adhesive coated discs followed by colour measurements after staining the cells. In this study, the correlation between stratum corneum (SC) hydration and scaling was investigated using capacitance measurements and squamometry, respectively.

METHODS

Stratum corneum hydration and assessment of barrier function by transepidermal water loss (TEWL) measurements were carried out on different sites of left and right volar forearm skin of female volunteers (n = 13; 24 +/- 3 years). D-Squame samples were taken on the same test spots.

RESULTS

Visual evaluation of the coloured samples by light microscopy and the development of a four-point-scale scoring system was found to be necessary to detect and minimise overestimation of chroma C* values. Capacitance measurements revealed neither significant differences between corresponding sites on left and right forearms no between different skin areas on the same forearm. Squamometric measurements, on the contrary, did not show any symmetry between corresponding test sites on both forearms or between different sites on one forearm. No correlation could be found between squamometric measurements and SC hydration values obtained at the same test sites. No skin barrier function impairment lays at the origin of this observation since TEWL values were found to be similar at all test sites in comparison to control skin. In a randomised single blind study, hydration and TEWL showed a significant improvement of 25% and 15%, respectively, after a 14-day application period of a moisturising cream. Although visual scoring of the coloured samples of both treated and untreated test spots revealed a good correlation with chroma C* values, the quantitative results found with squamometry were very doubtful.

CONCLUSION

Squamometry with visual scoring can be proposed as a screening technique for SC hydration rather than a quantitative method to appreciate skin moisturisation.

Beneficial effects of a skin tolerance-tested moisturizing cream on the barrier function in experimentally-elicited irritant and allergic contact dermatitis

In experimentally-induced irritant (ICD) and allergic (ACD) contact dermatitis, an oil-in-water (o/w) cream was applied to investigate its effects on a disturbed barrier function compared to untreated physiological barrier repair. Transepidermal water loss (TEWL) measurements were performed. Before the start of the experiments, the skin tolerance of the cream was examined, revealing the non-irritating characteristics of the ingredients and the absence of any contact allergic patch test reaction. In the ICD study, sodium lauryl sulfate (SLS) patches were applied to the forearms of young female volunteers. Consequently, it was observed that repeated cream application (14 days, 2x/day) significantly improved the TEWL of SLS-damaged skin, leading to a complete recovery on day 15. In the ACD study, disruption of skin barrier function was obtained by a nickel-mediated contact allergy patch (CAP) test. The cream was then applied 2x/day for 4 consecutive days. Assessment of TEWL clearly showed that recovery of the disrupted skin significantly improved after cream application in comparison to untreated barrier repair.

Melanoma screening: results of the first one-day campaign in Belgium ('melanoma Monday')

BACKGROUND

Although the incidence of melanoma is increasing and many informative campaigns have been organized. The general population is still little informed about this tumour.

AIMS

To organize a media campaign, with more relevant information and the opportunity for free skin inspections.

METHODS

A 'Task Force' organized a media campaign in April 1999 and convinced 65% of the Belgian dermatologists to give up 4 h of their time to do free skin examinations for skin cancer on Monday 26 April 1999; it was called 'Melanoma Monday'.

RESULTS

A total 2767 patients were screened. We found 25 melanomas and suspected 59 basal cell carcinomas. In the following 4 weeks another 141 melanomas were found. These 166 melanomas found in one month represent 15-20% of the total number of melanomas per year in Belgium.

SUMMARY

A media campaign with relevant information combined with screening opportunities can lead to the early detection of melanomas in a large number of patients and can continue to alert people at risk in the following weeks.

Microrelief of the skin using a light transmission method

The recently developed Skin Visiometer, based on light transmission through blue-coloured silicone replicas, was used to study skin microrelief. Calibrated metal plates displaying lines with depths between 6 and 361 microns, were used to determine the accuracy, sensitivity and reproducibility of the technique as well as the parameters of importance during measurement. The precision of the measurements was particularly good between 10 microns and 361 microns. The sensitivity of the method was between 10 and 20 microns. Replicas of volar forearm skin were taken from four groups (n = 15) of male and female volunteers in the age ranges 20 to 30 years and 55 to 65 years. In addition to the instrumental roughness parameters (Rz, Rt, Rm and Ra), the surface of the furrows, the number of primary and secondary lines and the number of intersections were determined. For both sexes, significantly lower values were observed for Rz, Rm and Rt in the younger age group than in the older age group. In addition, the numbers of primary and secondary lines and the number of intersections were higher, pointing to a more structured microrelief in younger forearm skin. Diurnal rhythm, the relative humidity of the measuring room and the position of the forearm were found to be significant factors, while room temperature and precleansing of the skin with mild products were not. Following the application of a hydrating cream (twice daily for 14 days) to the forearm skin of the older female age group, the Rz, Rt, Rm and Ra decreased, while the other parameters measured, except for the surface taken in by the lines, increased, indicating that the microrelief was modified towards the typical pattern observed in young skin.

Recurrent contagious ecthyma (Orf) in an immunocompromised host successfully treated with cryotherapy

A 48-year-old patient under immunosuppressive therapy for renal transplantation had contagious ecthyma which relapsed after excision. Stable healing was obtained by cryotherapy.

Subcorneal pustular dermatosis treated with PUVA therapy. A case report and review of the literature

BACKGROUND

Subcorneal pustular dermatosis (SPD) is a chronic recurrent pustular dermatosis of unknown etiology. Many treatments have been proposed, none of which has been uniformly successful.

OBJECTIVE

Our purpose is to report a patient with SPD successfully treated by PUVA and to review the literature concerning phototherapy treatment of SPD.

METHODS

A patient suffering from SPD resistant to diaminodiphenylsulphone (dapsone) responded well to a combination therapy consisting of dapsone and PUVA. He received 50 mg/day and 3 PUVA sessions a week. Photographs were taken at baseline and after 15 sessions.

RESULTS

The lesions were virtually cleared after 15 sessions. The patient remained free of lesions with a maintenance therapy of dapsone (50 mg/ day) and 1 PUVA session a week.

CONCLUSION

The therapeutic value of phototherapy for the treatment of SPD still has to be confirmed and could be a valuable alternative for treatment-resistant patients.

Incorporation of ceramide 3B in dermatocosmetic emulsions: effect on the transepidermal water loss of sodium lauryl sulphate-damaged skin

BACKGROUND

In previous work we reported on the efficacy of cosmetic body lotions enriched with skin-identical lipids to reduce the transepidermal water loss (TEWL) of ageing and sodium lauryl sulphate (SLS)-damaged skin. The observations made depended on the experimental design and clearly raised the question of the importance of the galenic formulation of skin ceramide-containing products.

OBJECTIVES

The aim of the present work was to study the different galenic forms in which ceramide 3B (0.2% w/v) can be incorporated into common o/w emulsions. In addition, we investigated whether supplementation of skin care products with ceramide 3B enriched with penetration enhancers and coemulsifiers could exert a beneficial effect on barrier function, done by measuring their effects on the TEWL of SLS-induced scaly skin.

RESULTS

We found that the technique of incorporating ceramide 3B into the o/w emulsions was important for their final stability. However, no additional positive effect on the TEWL values of SLS-damaged skin could be observed when the efficacy of the ceramide-containing emulsions was compared with that of proper controls.

CONCLUSIONS

Although suitable galenic formulas were developed, no positive effect on TEWL could be observed when ceramide 3B was added in a final concentration of 0.2% (w/v) to different o/w emulsions and applied to SLS-damaged skin.

Claim substantiation and efficiency of hydrating body lotions and protective creams

In the present work a practical claim substantiation study is shown by the example of 5 commercially available body lotions. Their efficacy with respect to effects on transepidermal water loss (TEWL) and stratum corneum (SC) hydration of ageing skin has been examined. Results were obtained after single and repeated application (14 days, 2 x a day). The best performing product was then selected and further tested for its potential effects on sodium lauryl sulfate (SLS)-damaged skin. This was done in a younger population and the recovery of the impaired barrier function was followed by TEWL measurements. The selected body lotion had a high efficacy, improving both the TEWL and SC hydration of ageing skin by more than 30%. When applied to SLS-damaged skin, the product was able to improve skin barrier repair in comparison with physiological barrier repair. The results of this study show that a combination of non-invasive objective measurements can be used to substantiate product claims. Claims can be made with respect to protective and preventive properties of products, but also as to effectiveness of topical skin treatment in the case of abnormal barrier function or barrier restoration.

Achilles foot screening project: preliminary results of patients screened by dermatologists

OBJECTIVE

Presentation of the preliminary results from the foot screening project, 'Achilles', conducted in spring of 1997 and 1998 in several European countries. At the EADV congress, only the preliminary results of the study, i.e. patients screened by dermatologists, were presented.

SUBJECT

Foot diseases, especially fungal infections (tinea pedis and onychomycosis).

METHODS

A questionnaire and a mycological examination in patients visiting a dermatologist for disorders irrespective of their foot problems.

RESULTS

The proportion of patients with foot diseases visiting a dermatologist was high (58%). In the total population, fungal infections were the most prevalent clinically diagnosed foot diseases (35%), especially onychomycosis (23%) and tinea pedis (22%). The prevalence of foot diseases increased with advancing age and more men as compared with women had fungal infections of the feet. The most prevalent predisposing factors were vascular disease and sports participation. In subjects with onychomycosis, the big toenail was affected most often. Twenty-three percent of the participants with clinically diagnosed tinea pedis and/or onychomycosis had infection of both the skin and the nail. The most frequently isolated pathogen was Trichophyton rubrum. Patients with onychomycosis often reported quality of life problems, especially pain and discomfort in walking.

CONCLUSION

The preliminary results of this pan-European study show that epidemiological studies can give a better idea of foot diseases in dermatological patients. The results indicate a need to pay more attention to foot disease, to predict and prevent future diseases and complications. The most frequent foot diseases were fungal infections, especially onychomycosis, which affects the quality of life of the patients. More results will be available in 1999.

Capillary-venous malformation in the labia majora in a 12-year-old girl

The case of a capillary-venous malformation in the labia majora of a 12-year-old girl is reported. The tumour increased in volume with puberty. The authors present a differential diagnosis between immature haemangioma and vascular malformation. The diagnosis is based on clinical examination, ultrasound, nuclear magnetic resonance, arteriography and gynaecological exploration. This malformation can be excised locally.

Healing of full-thickness wounds in pigs: effects of occlusive and non-occlusive dressings associated with a gel vehicle

This study, based upon a pig model, was conducted to investigate the effects of moist and dry healing conditions on wound closure (epithelialization, granulation tissue, contraction) of full-thickness wounds. Thirty-two full-thickness square wounds (3 cm x 3 cm) covered with either an occlusive polyurethane dressing (Tegaderm) or a non-occlusive dressing (Melolin) were evaluated. The effect of the presence or the absence of a gel (3% Idroramnosan) was also investigated with both dressings. The dressings were renewed twice a week. The time required for wound closure was 19.2 +/- 1.6 days for Tegaderm and 26.6 +/- 3.0 days (means +/- SD) for Melolin, respectively. The healing time of the full-thickness porcine wounds was significantly (P < 0.001) reduced by the occlusive dressing. Equivalent results were found with the 3% gel, indicating that the gel can be used as a neutral vehicle. The healing rate, calculated according to Gilman's method, was also significantly (P < 0.001) enhanced by the occlusive dressing. This progression was 0.073 +/- 0.004 cm/day and 0.050 +/- 0.009 cm/day (means +/- SD) for Tegaderm and Melolin, respectively. The contribution of contraction to wound closure was similar in all wounds, indicating that the occlusive dressing did not have an effect on wound contraction. Histological evaluation was performed on full-thickness skin biopsies of whole wound harvested from the time of wound closure to 3 months after. At any time point, no significant histological variations were observed between the different treated wounds. This study demonstrates in a porcine model that for full-thickness wounds, as for split-thickness wounds, occlusive dressing enhances healing rate and shortens the time for wound repair. The shortened healing time is a function primarily of the effect of occlusive dressing on epithelialization, especially the third phase of wound resurfacing.

Antifungal pulse therapy for onychomycosis. A pharmacokinetic and pharmacodynamic investigation of monthly cycles of 1-week pulse therapy with itraconazole

BACKGROUND AND DESIGN

In the treatment of onychomycosis, oral therapies have generally been given as a continuous-dosing regimen. For example, the suggested dose of itraconazole for the treatment of onychomycosis has thus far been 200 mg/d for 3 months. Based on the advances in our understanding of the pharmacokinetics of itraconazole, we investigated the efficacy and nail kinetics of intermittent pulse-dosing therapy with oral itraconazole in patients who were suffering from onychomycosis. Fifty patients with confirmed onychomycosis of the toenails, predominantly Trichophyton rubrum, were recruited and randomly assigned to three (n = 25) or four (n = 25) pulses of 1-week itraconazole therapy (200 mg twice daily for each month). Clinical and mycological evaluation of the infected toenails, and determination of the drug levels in the distal nail ends of the fingernails and toenails, were performed at the end of each month up to month 6 and then every 2 months up to 1 year.

RESULTS

In the three-pulse treatment group, the mean concentration of itraconazole in the distal ends of the toenails ranged from 67 (month 1) to 471 (month 6) ng/g, and in the distal ends of the fingernails, it ranged from 103 (month 1) to 424 (month 6) ng/g. At month 11, the drug was still present in the distal ends of the toenails at an average concentration of 186 ng/g. The highest individual concentrations of 1064 and 1166 ng/g were reached at month 6 for toenails and fingernails, respectively. At end-point follow-up, toenails in 84% of the patients were clinically cured with a negative potassium hydroxide preparation and culture in 72% and 80% of the patients, respectively. In the four-pulse treatment group, the mean concentration of itraconazole in the distal ends of the toenails ranged from 32 (month 1) to 623 (month 8) ng/g, and in the distal ends of the fingernails, it ranged from 42 (month 1) to 380 (month 6) ng/g. The highest individual concentrations of 1549 and 946 ng/g were reached at month 7 for toenails and at month 9 for fingernails, respectively. At month 12, the drug was still present in the distal ends of the toenails at an average concentration of 196 ng/g. At end-point follow-up, toenails in 76% of the patients were clinically cured with a negative potassium hydroxide preparation and culture in 72% and 80% of the patients, respectively. There were no significant intergroup differences between the three- and four-pulse treatment groups for the primary efficacy parameters. The drug was well tolerated with no significant side effects in either patient group.

CONCLUSIONS

Following pulse therapy with itraconazole (400 mg/d given for 1 week each month for 3 to 4 months), the drug has been detected in the distal ends of nails after the first pulse, and it has reached therapeutic concentrations with further therapy. After stopping the last pulse, the drug remains in the nail plate at levels above 300 ng/g for several months. Clinical cure rates between 76% and 84% and negative mycological examination findings between 72% and 80%, respectively, were observed in toenail onychomycosis. The data suggest that pulse therapy with itraconazole is an effective and safe treatment option for onychomycosis.

Vesiculopustular eruption associated with mycoplasma pneumoniae pneumopathy

A 43-year-old Caucasian male, hospitalised with a severe Mycoplasma pneumoniae infection of the respiratory tract developed subcorneal pustular dermatosis. After 3 months of treatment with dapsone 50 mg daily, all skin lesions disappeared without recurrences.

Unusual clinical manifestation of a disfiguring necrobiotic granulomatous disease

A 39-year-old woman had a disfiguring granulomatous disease of 36 years' duration. Nodules appeared on her lower extremities and later extended to her face; this led to ulceration and destruction of the nasal cartilage. This disease of unknown origin does not conform to any previously described entity. Some patients with a similar case presentation have been observed in France.

Pulse therapy with one-week itraconazole monthly for three or four months in the treatment of onychomycosis

In an open study, twenty-eight patients with toenail onychomycosis were treated with monthly cycles of 400 mg itraconazole daily for one week for three (n = 5) or four (n = 23) consecutive months. In this patient sample, a total of seventy-one toenails were affected, with a mean nail-plate involvement of 55 percent (range, 20 to 100 percent). Trichophyton rubrum was the most frequently isolated pathogen, followed by T. mentagrophytes. After active therapy, patients were evaluated for a maximum period of two years (mean, twelve months). A total of twenty-six of twenty-eight patients (93 percent) were considered as clinically cured. Of the remaining two patients, one was markedly improved and one appeared to have relapsed. Only three of seventy-one nails still exhibited some pathologic involvement. Of the twenty-six patients considered cured, mycologic examination at the final visit was performed on thirteen and the results were negative in all of them. The remaining clinically cured patients had no mycologic examination at the last visit. This short treatment was well tolerated; the only adverse reaction being a mild headache in one patient. Patients preferred this regimen to receiving daily treatment for three months. Pulse therapy consisting of monthly one-week cycles of 400 mg itraconazole daily for three to four months may offer a new option for treatment of onychomycosis. Further large-scale studies are required to confirm these findings.

Treatment of epidermolysis bullosa with human cultured epidermal allografts

Junctional epidermolysis bullosa letalis type Herlitz Pearson is a genetically determined, life-threatening disease. Effective therapy has been lacking to date. Therefore any therapy that improves wound healing would be beneficial for these patients. Cultured epidermal grafts are known to enhance wound epithelialization and have been used with success in some epidermolysis bullosa disorders. Encouraged by these reports, we grafted cultured allogeneic keratinocytes to an infant with a junctional epidermolysis bullosa letalis type.

New approaches to the treatment of onychomycosis

The purpose of this article is to review the pharmacologic properties of two newer agents, itraconazole and terbinafine, and to assess their clinical efficacy in onychomycosis. Both drugs are effective in treating infections caused by dermatophytes. Itraconazole appears to be more efficacious in infections caused by Candida species. The improved effectiveness of these agents is probably related to their rapid penetration into the nails and prolonged bioavailability at the site of infection.

Posttreatment itraconazole levels in the nail. New implications for treatment in onychomycosis

BACKGROUND

A problem in the treatment of onychomycosis is the lengthy duration of therapy. The pharmacokinetics of itraconazole suggest a potential for briefer treatment.

OBJECTIVE

This study was designed to investigate itraconazole nail kinetics in 39 patients with onychomycosis in relation to their therapeutic outcome.

METHODS

All patients received itraconazole for 3 months at a dose of 100 or 200 mg daily. Itraconazole levels of distal nail clippings were determined during a 6-month posttherapy period.

RESULTS

Therapeutic itraconazole concentrations were found in the nail plates of fingernails and toenails for up to 6 months after treatment. Cure of the toenails was observed in 79% of the patients treated with the 200 mg dosage and in 26% of those treated with 100 mg at 6 months after therapy.

CONCLUSION

The data suggest that the drug reaches the nail via incorporation into the matrix and by diffusion from the nail bed and is eliminated with regrowth of the nail after discontinuation of treatment.

Hair casts

Hair casts are small cylindrical structures, encircling individual scalp hairs but easily movable along the involved hair shafts. This hair disorder of unknown pathogenesis is only rarely mentioned in the dermatologic literature. We report the case of a 5-year-old girl, who has been treated during 2 years for pediculosis capitis. The literature about hair casts is reviewed.