Chitosomes-In-Chitosan Hydrogel for Acute Skin Injuries: Prevention and Infection Control

Burns and other skin injuries are growing concerns as well as challenges in an era of antimicrobial resistance. Novel treatment options to improve the prevention and eradication of infectious skin biofilm-producing pathogens, while enhancing wound healing, are urgently needed for the timely treatment of infection-prone injuries. Treatment of acute skin injuries requires tailoring of formulation to assure both proper skin retention and the appropriate release of incorporated antimicrobials. The challenge remains to formulate antimicrobials with low water solubility, which often requires carriers as the primary vehicle, followed by a secondary skin-friendly vehicle. We focused on widely used chlorhexidine formulated in the chitosan-infused nanocarriers, chitosomes, incorporated into chitosan hydrogel for improved treatment of skin injuries. To prove our hypothesis, lipid nanocarriers and chitosan-comprising nanocarriers (≈250 nm) with membrane-active antimicrobial chlorhexidine were optimized and incorporated into chitosan hydrogel. The biological and antibacterial effects of both vesicles and a vesicles-in-hydrogel system were evaluated. The chitosomes-in-chitosan hydrogel formulation demonstrated promising physical properties and were proven safe. Additionally, the chitosan-based systems, both chitosomes and chitosan hydrogel, showed an improved antimicrobial effect against S. aureus and S. epidermidis compared to the formulations without chitosan. The novel formulation could serve as a foundation for infection prevention and bacterial eradication in acute wounds.

Infections in Dupilumab Clinical Trials in Atopic Dermatitis: A Comprehensive Pooled Analysis

BACKGROUND

Patients with moderate-to-severe atopic dermatitis (AD) have increased infection risk, including skin infections and systemic infections. Immunomodulators (e.g., anti-tumor necrosis factors, anti-interleukin [anti-IL]-23, anti-IL-17, Janus kinase inhibitors) increase risk of infections. Dupilumab (a monoclonal antibody blocking the shared receptor component for IL-4 and IL-13) is approved for inadequately controlled moderate-to-severe AD and for moderate-to-severe eosinophilic or oral corticosteroid-dependent asthma.

OBJECTIVE

The aim was to determine the impact of dupilumab on infection rates in patients with moderate-to-severe AD.

METHODS

This analysis pooled data from seven randomized, placebo-controlled dupilumab trials in adults with moderate-to-severe AD. Exposure-adjusted analyses assessed infection rates.

RESULTS

Of 2932 patients, 1091 received placebo, 1095 dupilumab 300 mg weekly, and 746 dupilumab 300 mg every 2 weeks. Treatment groups had similar infection rates overall per 100 patient-years (placebo, 155; dupilumab weekly, 150; dupilumab every 2 weeks, 156; dupilumab combined, 152), and similar non-skin infection rates. Serious/severe infections were reduced with dupilumab (risk ratio 0.43; p < 0.05), as were bacterial and other non-herpetic skin infections (risk ratio 0.44; p < 0.001). Although herpesviral infection rates overall were slightly higher with dupilumab than placebo, clinically important herpesviral infections (eczema herpeticum, herpes zoster) were less common with dupilumab (risk ratio 0.31; p < 0.01). Systemic anti-infective medication use was lower with dupilumab.

CONCLUSIONS

Dupilumab is associated with reduced risk of serious/severe infections and non-herpetic skin infections and does not increase overall infection rates versus placebo in patients with moderate-to-severe AD. CLINICALTRIALS.

GOV IDENTIFIERS

NCT01548404, NCT02210780, NCT01859988, NCT02277743, NCT02277769, NCT02260986, and NCT02755649.

Connecting the Dots: From Skin Barrier Dysfunction to Allergic Sensitization, and the Role of Moisturizers in Repairing the Skin Barrier

The skin is one of the largest immunologic organs in the body and a continuous target for allergic and immunologic responses. Impairment of the skin barrier increases the likelihood of external antigens and pathogens entering and creating inflammation, which can potentially lead to skin infections, allergies, and chronic inflammatory diseases such as atopic and contact dermatitis. Functionally, the skin barrier can be divided into four different levels. From outermost to innermost, these highly interdependent levels are the microbiome, chemical, physical, and immune levels. The objective of this review is to provide an update on current knowledge about the relationship between skin barrier function and how dysfunction at each level of the skin barrier can lead to allergic sensitization, contact dermatitis, and the atopic march, and examine how to best repair and maintain this barrier through the use of moisturizers. J Drugs Dermatol. 2019;18(6):581-586.

Synthetic Turf: History, Design, Maintenance, and Athlete Safety

CONTEXT:

Synthetic turf has become an increasingly common playing surface for athletics and has changed dramatically since its introduction more than 50 years ago. Along with changes to surface design, maintenance needs and recommendations have become more standardized and attentive both to upkeep and player-level factors. In particular, synthetic turf maintenance as it relates to athlete health and safety is an important consideration at all levels of play.

EVIDENCE ACQUISITION:

A literature search of MEDLINE and PubMed for publications between the years 1990 and 2018 was conducted. Keywords included s ynthetic turf, artificial turf, field turf, and playing surface. Additionally, expert opinion through systematic interviews and practical implementation were obtained on synthetic turf design and maintenance practices in the National Football League.

STUDY DESIGN:

Clinical review.

LEVEL OF EVIDENCE:

Level 5.

RESULTS:

Synthetic turf has changed considerably since its inception. Playing surface is a critical component of the athletic environment, playing a role both in performance and in athlete safety. There are several important structural considerations of third-generation synthetic turf systems currently used in the United States that rely heavily on strong and consistent maintenance. A common misconception is that synthetic turf is maintenance free; in fact, however, these surfaces require routine maintenance. Whether athletes experience more injuries on synthetic over natural surfaces is also of interest among various levels and types of sport.

CONCLUSION:

Modern synthetic turf is far different than when originally introduced. It requires routine maintenance, even at the level of local athletics. It is important for sports medicine personnel to be familiar with playing surface issues as they are often treating athletes at the time of injury and should maintain a level of awareness of contemporary research and practices regarding the relationships between synthetic turf and injury.

Skin Infections: Which Student-Athletes Are at Greatest Risk?

Skin infections are a common ailment that affect all students, with increased risk to those students participating in sport and specifically contact sports. The types of skin infections that students are likely to encounter are categorized into three types: (a) bacterial, (b) viral, and (c) fungal. All three types of infection can appear benign at onset but can grow into serious disease and illness if not correctly identified and treated in a timely manner. A strong prevention program should be in place at all schools with appropriate resources in place (human and financial) to carry out proper cleaning of facilities, on-site examination by the school nurse or athletic trainer, and sufficient education of coaches, athletes, parents and administrators.

Reducing injecting-related injury and diseases in people who inject drugs: Results from a clinician-led brief intervention

BACKGROUND

The burden of disease associated with injecting-related injury and diseases (IRIDs) is significant among people who inject drugs (PWID).

OBJECTIVE

The aim of this study was to evaluate a clinician-led brief intervention involving safer injecting messages and demonstration of safer injecting techniques at the time of venepuncture for serological testing.

METHODS

We conducted a before and after evaluation study. History of IRIDs and injecting-related risk behaviours were assessed and compared at baseline and follow-up.

RESULTS

Fifty-eight participants completed the pre-intervention and post-intervention evaluation surveys. Compared to baseline, at follow-up fewer participants reported not cleaning their hands prior to injecting (16% cf 31%; P = 0.039); more reported applying a tourniquet correctly (38% cf 24%; P = 0.008), never missing a vein (56% cf 31%; P = 0.007), and applying pressure for at least one to two minutes after injecting (33% cf 13%; 
P = 0.035).

DISCUSSION

The intervention was found to be feasible, justifying its inclusion into routine clinical care. We recommend that other health services targeting PWID implement similar interventions.

The diabetic foot in 2015: an overview

In 2015, it can be said that the diabetic foot is no longer the Cinderella of diabetic complications. Thirty years ago there was little evidence-based research taking place on the diabetic foot, and there were no international meetings addressing this topic. Since then, the biennial Malvern Diabetic Foot meetings started in 1986, the American Diabetes Association founded their Foot Council in 1987, and the European Association for the Study of Diabetes established a Foot Study Group in 1998. The first International Symposium on the Diabetic Foot in The Netherlands was convened in 1991, and this was soon followed by the establishment of the International Working Group on the Diabetic Foot that has produced useful guidelines in several areas of investigation and the management of diabetic foot problems. There has been an exponential rise in publications on diabetic foot problems in high impact factor journals, and a comprehensive evidence-base now exists for many areas of treatment. Despite the extensive evidence available, it, unfortunately, remains difficult to demonstrate that most types of education are efficient in reducing the incidence of foot ulcers. However, there is evidence that education as part of a multi-disciplinary approach to diabetic foot ulceration plays a pivotal role in incidence reduction. With respect to treatment, strong evidence exists that offloading is the best modality for healing plantar neuropathic foot ulcers, and there is also evidence from two randomized controlled trials to support the use of negative-pressure wound therapy in complex post-surgical diabetic foot wounds. Hyperbaric oxygen therapy exhibits the same evidence level and strength of recommendation. International guidelines exist on the management of infection in the diabetic foot. Many randomized trials have been performed, and these have shown that the agents studied generally produced comparable results, with the exception of one study in which tigecycline was shown to be clinically inferior to ertapenem ± vancomycin. Similarly, there are numerous types of wound dressings that might be used in treatment and which have shown efficacy, but no single type (or brand) has shown superiority over others. Peripheral artery disease is another major contributory factor in the development of ulceration, and its presence is a strong predictor of non-healing and amputation. Despite the proliferation of endovascular procedures in addition to open revascularization, many patients continue to suffer from severely impaired perfusion and exhaust all treatment options. Finally, the question of the true aetiopathogenesis of Charcot neuroarthropathy remains enigmatic, although much work is currently being undertaken in this area. In this area, it is most important to remember that a clinically uninfected, warm, insensate foot in a diabetic patient should be considered as a Charcot foot until proven otherwise, and, as such, treated with offloading, preferably in a cast.

Aryl-Alkyl-Lysines: Agents That Kill Planktonic Cells, Persister Cells, Biofilms of MRSA and Protect Mice from Skin-Infection

Development of synthetic strategies to combat Staphylococcal infections, especially those caused by methicillin resistant Staphyloccus aureus (MRSA), needs immediate attention. In this manuscript we report the ability of aryl-alkyl-lysines, simple membrane active small molecules, to treat infections caused by planktonic cells, persister cells and biofilms of MRSA. A representative compound, NCK-10, did not induce development of resistance in planktonic cells in multiple passages and retained activity in varying environments of pH and salinity. At low concentrations the compound was able to depolarize and permeabilize the membranes of S. aureus persister cells rapidly. Treatment with the compound not only eradicated pre-formed MRSA biofilms, but also brought down viable counts in bacterial biofilms. In a murine model of MRSA skin infection, the compound was more effective than fusidic acid in bringing down the bacterial burden. Overall, this class of molecules bears potential as antibacterial agents against skin-infections.

Incontinence-associated dermatitis and pressure ulcers in geriatric patients

The key characteristics of geriatric patients are advanced age, multimorbidity, a decrease of psychical performance and care dependency. In addition, advanced age, chronic and acute diseases and treatments (e.g. polypharmacy) lead, either directly or indirectly, to a wide range of skin and tissue problems. Incontinence-associated dermatitis and pressure ulcers (PUs) belong to the most prevalent in geriatric settings. Prolonged exposure of the skin to urine and/or stool can cause an irritant contact dermatitis. Skin surface 'wetness', increased skin surface pH, digestive intestinal enzymes, repeated skin cleansing activities, and a possible occlusive environment contribute to irritation and inflammation. Prevention and treatment includes activities to maintain and to enhance continence and to limit, to reduce exposure of the skin to urine and stool, and to promote healing and reepithelialisation. In frail aged skin, it is recommended to use incontinence products with smooth and breathable materials with maximum absorption capacity. Immediate skin cleansing after soiling using mild cleansers and protective and caring leave-on products are recommended. PUs are localized injuries to the skin and/or underlying tissue caused by sustained deformations of skin and underlying soft tissues. PUs management includes risk assessment, repositioning and mobilization, and the use of appropriate support surfaces. Patients must be never positioned directly on an existing PU. Especially at end of life, the PU closure and wound healing may not be the primary therapeutic goal.

Atopic Dermatitis: A Common Pediatric Condition and Its Evolution in Adulthood

Atopic dermatitis (AD) is a chronic and pruritic inflammatory skin disorder that has a relapsing course and can affect any age group. Patients with AD have higher rates of other allergic disorders, mental health disorders, and skin infections. An important feature of AD for practitioners to recognize is that the clinical presentation varies by age from infancy into adulthood. The goals of treatment and management of AD focuses on restoring and maintaining the skin barrier function, minimizing inflammation, breaking the itch-scratch cycle, and treating possible external triggers and secondary infections that may propagate AD.

Management of adult patients with buttock and perineal burns: The Ross Tilley Burn Centre experience

BACKGROUND

Perineal and buttock burns are challenging wounds to heal for several reasons because of the contamination risk and shear stress that is always present. Because of the nature of the wound bed, pathogens can have ready access to create systemic infections and complications. Prolonged healing times also delay the recovery for patients and add to their discomfort and psychological stress from the injury. The ideal treatment approach is not well defined, and the aims of this study were to conduct a literature review of current treatment suggestions and to look at our own patient population to determine how our center treated these challenging patients.

METHODS

This is a retrospective review of all patients treated between 2010 and 2013 at our center. Patients that received care for burns to the perineum or buttocks were evaluated. Mortalities within 24 hours of admission and transfers before completion of their care were excluded. All patients older than 18 years were included in the study. The primary outcome studied was a cause for graft revision. Secondary outcomes included benefits and risks of fecal management devices, risk of infection, and mortality.

RESULTS

The literature review did not show consensus on how to best manage this patient population. Our results however demonstrated that patients treated with the fecal management device Flexi-seal (Convatec, Skillman, NJ) were at increased risk of developing an infection involving an enteric pathogen and requiring revision procedures. The patient population that was treated with this device was also older and had larger burns. The patients within this group that were treated initially with allograft required fewer revisions when compared with patients that received autograft in this group (23% vs. 34%, p > 0.05).

CONCLUSION

After our data and the literature had been reviewed, the lack of evidence-based treatment protocols led us to create recommendations for burn surgeons with regard to the initial management of this complicated area. Certain key features include avoiding autograft at the primary excision if they have an increased revised Baux score and minimizing the amount of liquid stool contaminating the wound bed to increase success.

LEVEL OF EVIDENCE

Epidemiologic study, level IV. Therapeutic study, level V.

New and emerging vaccination strategies for prevention and treatment of dermatological diseases

Accelerated by the rapid advancements of our understanding of the molecular and cellular pathology of diseases and of the components and mechanisms of cellular and humoral immune responses, new vaccination strategies are being developed and explored for treatment and prevention of infectious diseases, cancer, autoimmune disorders and allergies. Many newly developed vaccination strategies are already in clinical trials, some with very promising results. Although most of these strategies are still at very early stages of their development, it is foreseeable that vaccination will evolve to play an important role in prevention, treatment and management of all the above classes of diseases.

Nurse-led school-based clinics for skin infections and rheumatic fever prevention: results from a pilot study in South Auckland

AIM

To assess the acceptability and feasibility of delivering targeted primary health care in a decile one primary school setting.

METHOD

A pilot public health nurse (PHN)-led clinic was set up in a South Auckland primary school (roll approximately 400). The clinic was based on a previous sore throat clinic model with modifications aimed at improving programme feasibility and effectiveness. The timely identification and treatment of Group A Streptococcal (GAS) throat infections to prevent rheumatic fever (RF), and the prevention and treatment of four skin infections (cellulitis, impetigo, infected eczema and scabies) were the focus. The pilot ran for 15 weeks from April to July 2011. Evaluation included documentation review, key school and healthcare stakeholder interviews and parent questionnaires.

RESULTS

The consent rate was 92.2%. Of a total 722 throat swabs taken from 337 students, 94 were GAS positive. Ninety-eight assessments of skin conditions were completed at which 76 had a skin infection diagnosed, the most common infection being impetigo (n=46). Thirty-one skin infections were diagnosed in the first week of the pilot. PHN workload was high with a total of 539 phone calls, 137 home visits and 51 school-based parent consultations. The approach was highly acceptable to the majority of key stakeholders. Extrapolating pilot costs results in an estimated annual cost of $510 per student for the programme.

CONCLUSION

It is likely to be both acceptable and feasible to take this model of delivering targeted primary health care to school aged children and use it on a larger scale. The complexity of providing this type of service should not be underestimated and it is essential that robust processes are in place to ensure smooth, safe running of such a programme. Long-term outcome evaluation will be vital to assess programme effectiveness.

Herpes rugbiorum: a review on scrum pox and rugby player guidelines

Sports, especially contact ones, have long been associated with an increased risk of contracting a communicable disease. Viral infections, in particular, have had an increased attention, due to their adverse effects on athletes' performance. As world sport events have now become more organised and diverse, athletes are now exposed to a wider range of pathogens. With the upcoming Rugby World Cup in 2011 taking place in New Zealand, team-doctors should keep a 'careful' eye on potential infectious outbreaks and make sure to adhere to guidelines accessed through fact sheets.

[Childhood diseases with exanthema]

- Due to high vaccination coverage, measles and rubella (German measles) are now rarely seen in the Netherlands, which makes recognition of these diseases difficult. - Measles can also occur in people who have been immunized, as a result of vaccination failure. - Swift recognition of measles and rubella is necessary in order to manage them adequately and to prevent spreading of the disease. - Measles, rubella, and erythema infectiosum ('fifth disease') may result in complications during pregnancy. - Measles, rubella, scarlet fever, erythema infectiosum, and roseola ('sixth disease') can be difficult to differentiate. - In the Netherlands, diagnosis of a patient with measles or rubella, or of more than 1 patient with erythema infectiosum within one institution, must be reported to the local health authority within 1 working day. - Exclusion from school or a day-care facility is not required for any if the diseases discussed.

[Efficiency of the use of nutriceutics and parapharmaceutics for the prevention of skin and subcutaneous fat infections]

The use of nutriceutics (hexavit (multivitamin) or the natural concentrated product (NCP) Atlant from the raw plant material) and the parapharmaceutic lyophilized bifidumbacterin to enhance natural resistance in the subjects of an organized collective body in skin and subcutaneous fat infections (SSFI) (furuncul, abscess, phlegmons, pyodermas) showed the increasing bactericidal activity of the skin, normalized composition of colonic microflora, decreases in primary morbidity from appealability rates and in SSFI morbidity. When the NCP was taken, prophylactic efficiency was higher, which was likely associated with its increased concentrations of antioxidant vitamins (A, E, and C) and minor components.

Dermatologic manifestations of HIV in Africa

Dermatologic disease is common in HIV-infected individuals, and clinicians caring for patients with HIV infection or AIDS in Africa are routinely confronted with skin problems in their patients. Scarce access to dermatologic specialty care and limited educational resources describing the unique clinical characteristics of HIV-related skin disease can make diagnosing and treating skin diseases a challenge in Africa. This article describes common HIV-related dermatologic conditions in Africa and their differential diagnoses and includes treatment strategies that are likely to be available locally. It is not meant to be comprehensive but rather to serve as a practical resource to aid practitioners by providing images of common conditions and describing distinctive clinical presentations of common conditions.

[Dynamics of the functional status of autonomic nervous system in rats under combined radiation/thermal injury in case of an open burn wound and wound covered by the polymer film]

The peculiarities of the functional status of autonomic nervous system and physical efficiency were studied in white inbred rats under dynamics of combined radiation/thermal injury (CR/TI). The CR/TI model was obtained under total X-ray irradiation at dose level of 4.37 Gy and inflicting III degree burn injury making 12% of body surface in 24 rats. The studies were performed under conditions of both spontaneous CR/TI development and protecting the burn wound against infection. In 12 rats the wounds were covered by polymer films treated with iodine and succinic acid. On days 3, 7, 14, 21 and 28 of CR/TI, as well as prior to CR/TI (datum level), heart rate variability (HRV) indices, the level of physical efficiency (the retention time of own weight on the vertical pole), indices of body mass, survival, and average life-soan of animals were recorded. For registration of ECG in awake rats, corrections of motor artifacts and analysis of HRV the original software program was used. R-R intervalograms were analyzed in time and frequency domains. The sliding window technique was used (100 R-R intervals with the step of 10 seconds; epoch of analysis--7 minutes). The obtained data indicated that the survival level and the average life-span in rats with the film-covered burn wound were higher as compared to the "pure" CR/TI. At the same time body mass and physical efficiency in animals of both groups did not differ in practice. Data on the functional status of autonomic nervous system were more informative. In rats with film-covered burn wound the dynamics of HRV indices had a biphasic character with the tending to normalization beginning from day 7 of CR/TI, whereas in case of an open wound HRV indices were characterized by monotonous growth until the end of observations. In the overall picture of the CR/TI in both groups of animals the sympathotropic effects of burn stress prevailed. Methods of mathematical analysis of HRV under conditions of CR/TI were for the first time used in this study. The research outcomes signify to the expediency to apply these methods for obtaining data on functional state of the autonomic nervous system in CR/TI models in small laboratory animals.

Successful strategies in atopic dermatitis management

Successful strategies for managing atopic dermatitis require an accurate diagnosis, identification and elimination of exacerbating factors including irritants and allergens, adequate hydration of the skin, control of pruritus and infections, and appropriate use of topical anti-inflammatory and other medications. Proper patient education increases the chances of successful therapy.

Vaccination against cutaneous and mucosal papillomavirus in cattle

Viruses are responsible for approximately 15% of human cancer worldwide. Human papillomavirus and hepatitis B virus are the recognized agents of cervical and liver cancer, respectively, which together constitute 80% of all virally induced cancers. If measures could be found to bring viral infection under control, a great proportion of human cancer would be greatly reduced. Experimental vaccines are being developed against papillomavirus. In principle two different types of vaccine can be envisaged: prophylactic vaccines that would elicit virus-neutralizing antibodies and would prevent infection and therapeutic vaccines that would induce regression of established lesions before progression to malignancy took place. The research on vaccines against human papillomavirus is hampered by the difficulties encountered in growing the virus in tissue culture and by the unacceptable nature of experimentation in humans. Effective vaccines, both natural and genetically engineered, have been developed against bovine papillomavirus and cottontail rabbit papillomavirus. The success obtained with the animal models supports the optimistic prediction that in the relatively near future vaccines will be available against the most problematic or potentially dangerous forms of papillomatosis in humans.

A Prospective Study to Compare Subcutaneously Buried Peritoneal Dialysis Catheter Technique with Conventional Technique

AIMS

To reduce peritoneal dialysis-related infections, Moncrief-Popovich (MP) designed a special catheter and implantation technique. Herein we report our experience of patients treated with the MP and conventional approach.

METHODS

A total of 214 patients were divided into three groups according to catheter type and implantation technique: group A received a MP catheter (MPC) via MP technique (n = 27); group B received Tenckhoff catheters via MP technique (n = 32), and group C received Tenckhoff catheters via conventional technique (n = 155). Data were collected for infection and catheter survival.

RESULTS

The catheter survival and peritonitis rate was similar in our study groups. Age was found to be the significant factor associated with peritonitis rate.

CONCLUSIONS

Although the MP technique was not associated with a lower peritonitis rate in our practice, the possible benefit of less healthcare costs is still considerable.

Cutaneous Infections Associated with HIV/AIDS

With diminished and dysregulated cell-mediated immunity, HIV-infected individuals are susceptible to a myriad of skin infections. These infections include the conditions encountered in immunocompetent patients, as well as infections seen almost exclusively in the setting of HIV infection. The HIV/AIDS pandemic has made some previously rare infections more prominent. Although antiretroviral therapy has been helpful in relieving the burden of cutaneous infections in HIV-infected patients, it does not prevent all opportunistic infections in the skin and also has created new dilemmas.

Protection of rabbits against cutaneous papillomavirus infection using recombinant tobacco mosaic virus containing L2 capsid epitopes

Cottontail rabbit papillomavirus (CRPV) and rabbit oral papillomavirus (ROPV) represent distantly related, cutaneous and mucosal tissue tropic papillomaviruses respectively that can infect the same host. These two viruses were used to test the effectiveness of an L2 peptide-based vaccine (aa 94-122) that was delivered on the surface of recombinant tobacco mosaic virus (rTMV) particles. Groups of NZW rabbits received combinations of CRPVL2, ROPVL2 and CRPV+ROPVL2 rTMV vaccines, and were then challenged with infectious CRPV and ROPV. The rabbits developed antibodies that reacted to whole L2 protein and these sera were able to neutralize CRPV pseudovirions at half-maximal titers that were between 50 and 500. Rabbits receiving the CRPV L2 vaccine alone or in combination with ROPV L2 vaccines were completely protected against CRPV infections. Those rabbits vaccinated with the ROPV L2 vaccines showed a weak response in some rabbits against CRPV infection. These studies demonstrate that L2-based vaccines provide strong protection against experimental papillomavirus infection that is most likely based upon the induction of virus-neutralizing antibody. Notably, we observed some limited cross-protection induced by the L2 sequences tested in these vaccines. Finally, the study demonstrated that rTMV were excellent agents for the induction of strong protection in a pre-clinical disease model of papillomavirus infection.

Prophylaxis for and treatment of uncomplicated skin and skin structure infections in laser and cosmetic surgery

Complications of laser resurfacing include infections, scarring, hyperpigmentation, hypopigmentation, and delayed healing. Postoperative infections cause pain, prolonged healing, and can result in scarring. Ablative laser techniques cause partial- or full-thickness wounds, whereas so-called "nonablative procedures" may cause "spotty" epidermal wounds. Antibiotic prophylaxis is necessary when the risk for postoperative infection is significant or when the risk of infection is moderate but the consequences of infection are significant. Prophylactic antibiotic agents should have a broad spectrum of activity, be well-tolerated and be safe. The most appropriate choice is a broad-spectrum agent such as cefdinir, even for patients allergic to penicillin. Additionally, all patients should be treated prospectively with antivirals to prevent activation and dissemination of herpes simplex virus type I. Treatment of infections in patients who have and have not received prophylactic antibiotics requires identification of the causative factor and appropriate treatment. Nonablative treatments such as photodynamic therapy do not usually require antibiotic prophylaxis, although a few patients treated for acne may acquire a secondary bacterial infection that should be treated.

Epidemiological assessment of mucocutaneous infections in patients with recurrent infection syndrome

BACKGROUND

Recurrent infection syndrome (RIS) results from repeated interactions between hosts and environmental infectious agents and is considered normal (NRIS) because of its benign evolution and positive effects in the development of normal immune responses. Abnormal RIS (ARIS) is characterized by the unusually high frequency of severe infections, either as a result of anatomical or functional abnormalities or due to primary or secondary immunodeficiencies (PIDs and SIDs, respectively). Recurrent mucocutaneous infections (MCIs) can be manifestations of RIS or ARIS and could be more frequent in primary immunodeficiencies. Similarly, etiologic agents might vary from what is observed in the general population.

METHODS

We carried out a descriptive study to determine the prevalence of aerobic bacterial and fungal mucocutaneous infections in 452 patients with recurrent infections, using clinical records to establish immunological status associated with the presence and characteristics of the infections. Microbiological analyses from mucocutaneous lesions were used to confirm the etiology.

RESULTS

We found mucocutaneous infections in 50 patients for a total of 62 episodes (bacterial or fungal infections in 38 vs. 12 patients, respectively). Mucocutaneous infections were more frequent (21.8% vs. 9.1%; OR = 2.8) and recurrent (8.7% vs. 0.2%; P = 0.000) in primary immunodeficient patients. Furthermore, those with defects in phagocytic cells presented more mucocutaneous infections (56.2%) than patients with other primary immunodeficiencies (11.3%; OR = 10.1).

CONCLUSIONS

Bacterial and fungal mucocutaneous infections are more frequent and severe in primary immunodeficient patients, particularly those with defective phagocytosis. Early and adequate assessment of the nature of mucocutaneous infections in ARIS should impact the ability of physicians to treat promptly, avoid complications and reduce the costs of medical assistance.

A clinician's paradigm in the treatment of atopic dermatitis

Successful management of atopic dermatitis requires a multipronged approach that includes skin barrier function care, use of topical or systemic agents, and identification and elimination of precipitating or exacerbating factors. Because the origin of atopic dermatitis is multifactorial and trigger factors differ among patients, treatment plans must be specific to the individual patient. This article offers an example of a permutational, or flexible, treatment paradigm. The approach utilizes 4 topical regimens--high-potency topical corticosteroids, lowest effective potency topical corticosteroids, topical calcineurin inhibitors (TCIs), or topical corticosteroid/TCI combinations--as initial therapy in a variety of induction protocols, as determined by the severity of a patient's condition and history. The paradigm permits treatment to progress from a chosen induction therapy to maintenance therapy. During the patient's induction therapy, as soon as an acceptable level of clearance is achieved, therapy should be adjusted to a maintenance regimen, such as monotherapy with either a TCI or a lowest effective potency topical corticosteroid (the latter used intermittently) or an alternation of the two agents. If there is no clearance or positive response with the initial induction protocol, the clinician should move to one of the alternative regimens.

Staphylococcus aureus re-colonization in atopic dermatitis: beyond the skin

Patients with atopic dermatitis (AD) are often heavily colonized by Staphylococcus aureus, which adversely affects eczema severity. Strategies to control S. aureus in AD include antibiotic and or antiseptics. However long-term efficacy is unclear. In this study we consider extra-cutaneous factors that may cause S. aureus re-colonization in adult AD. Twenty-one patients with AD were recruited and were assessed for: duration of AD, use of topical or oral antibiotic within the preceding 3 months, the number of hospital admissions during the preceding year and current treatment. The types of topical treatments used, vehicle, container and the expiry dates were also recorded. The severity of AD was assessed by SCORAD index. Microbiological assessment for S. aureus carriage from affected skin, anterior nares, emollient and topical steroid was undertaken using culture, Staphaurex test and antibiotic resistance. Of the patients 86% had S. aureus colonization. The median SCORAD score were greater in those colonized with S. aureus (P = 0.02) and those with contaminated treatments (P = 0.05). Prior antibiotic treatment, prior hospital admission and nasal carriage did not influence the median SCORAD. Three extra-cutaneous mechanisms by which S. aureus can re-colonize the skin were identified: antibiotic resistance, nasal carriage and treatment contamination.

Study and application of herbal disinfectants in China

Disinfection means killing or removing pathogenic microorganisms in media to realize a harmless process. A disinfectant, which is also referred to as a disinfection medicine in relevant regulations, is the medicine used to kill microorganisms for the purpose of disinfection. The disinfectants prepared from plants (including traditional Chinese herbal medicines) and the extracts thereof are called herbal disinfectants. China has a long history of using herbal disinfectants. As early as in 533 A.D., the use of Cornel to sterilize well water was recorded in Necessary Techniques for Qi People by Jia Enxie of the Beiwei Dynasty. During the Dragon Boat Festival, people often use fumigants made of traditional Chinese herbal medicines like Chinese Atractylodes, Argy Wormwood Leaf and Red Arsenic Sulfide to smoke their houses, so as to ward off plagues and drive away evils. In fact this is now a kind of disinfection practice.

Herpes gladiatorum and other skin diseases

Musculoskeletal injury, appropriately, is the focus of time-loss from practice and competition. Nevertheless, skin infections are responsible for between 10% and 15% of time-loss injuries at the collegiate level. The risk of contagion has resulted in specific treatments dictated by the National Collegiate Athletic Association(NCAA) and National Federation of State High School Associations (NFHS) before an athlete can participate. These guidelines make identification and treatment by the athlete's physician imperative. This article provides the clinician with specific direction in addressing these dermatologic disorders.

Vaccines and immunotherapies for the prevention of infectious diseases having cutaneous manifestations

Although the development of antimicrobial drugs has advanced rapidly in the past several years, such agents act against only certain groups of microbes and are associated with increasing rates of resistance. These limitations of treatment force physicians to continue to rely on prevention, which is more effective and cost-effective than therapy. From the use of the smallpox vaccine by Jenner in the 1700s to the current concerns about biologic warfare, the technology for vaccine development has seen numerous advances. The currently available vaccines for viral illnesses include Dryvax for smallpox; the combination measles, mumps, and rubella vaccine; inactivated vaccine for hepatitis A; plasma-derived vaccine for hepatitis B; and the live attenuated Oka strain vaccine for varicella zoster. Vaccines available against bacterial illnesses include those for anthrax, Haemophilus influenzae, and Neisseria meningitidis. Currently in development for both prophylactic and therapeutic purposes are vaccines for HIV, herpes simplex virus, and human papillomavirus. Other vaccines being investigated for prevention are those for cytomegalovirus, respiratory syncytial virus, parainfluenza virus, hepatitis C, and dengue fever, among many others. Fungal and protozoan diseases are also subjects of vaccine research. Among immunoglobulins approved for prophylactic and therapeutic use are those against cytomegalovirus, hepatitis A and B, measles, rabies, and tetanus. With this progress, it is hoped that effective vaccines soon will be developed for many more infectious diseases with cutaneous manifestations.

Total skin electron beam therapy and cutaneous T-cell lymphoma: a clinical guide for patients and staff

Total skin electron beam therapy (TSEBT) is a technically complicated treatment used in the management of mycosis fungoides (MF). A variety of technical and clinically oriented issues relating to TSEBT and its effects for patients with MF are reviewed.

[Thoughts about the "rade" disease in Norway--"it takes its victims slowly"]

Radesyge first appeared in south-western Norway in the middle of the 18th century; the endemic that followed was to haunt the region for close to one hundred years. The disease was characterized by severe wounds, often with bone decomposition. The face was frequently involved, causing striking malformations. Radesyge was at the time considered a serious threat to society and was the subject of intense public debate over several decades. Core components of the modern health care system in Norway can trace their origin to countermeasures taken to combat the spread of this disease. In this article, the author argues that rather than viewing radesyge as an outbreak of tertiary syphilis, which has been the custom for the last hundred years, it should, for scholarly purposes, be seen as a separate event. This is the only way to properly grasp the impact of the endemic on patients, society, politics and science at the time.

Infectious diseases and the returning traveller--experience from a regional infectious diseases unit over 20 years

The report from the Chief Medical Officer - Getting Ahead of the Curve (a strategy for combating infectious diseases) included the statement 'Infectious diseases recognize no international boundaries, so that a newly emergent disease in another part of the world must be assessed for a potential threat to this country'. About 50 million journeys abroad are made from the UK every year. Inevitably this brings many into contact with illness they would not otherwise impact. Over the last 20 years there has been a corresponding increase in the number of admissions to the Regional Infectious Diseases Unit in Sheffield that has risen from about 50 in 1985 to over 200 in 2000. Admissions reach their peak in the months of June, July, August and September. This review provides an overview of the infections seen in returning travellers in Sheffield over a 20-year period, including information on the countries where infection has been acquired and comments upon the measures which may be taken to minimize the risk of infection while travelling.

Laundering in the prevention of skin infections

The statistics at the Hohenstein Institutes and the detergent industry show that the number of complaints due to skin irritations or allergies of washed laundry are relatively low. A clear interdependence between the number of complaints and the season of the year is existing. An interesting fact is that work wear made of cotton shows a relatively higher number of complaints than blends of polyester with cotton. The highest number of complaints results from operating theatre textiles, which is probably due to the exceptional strain of the skin of the operating-theatre staff by surgical disinfecting measures. During washing in household washing machines and also in the industrial sector it is mainly the mechanical action of the washing machines and the chemistry of the detergents which influence the textiles. The effects of the washing process on the textiles if assessed regarding the dermatological point of view, can go in two different directions: Changes of the textile itself and the formation of residues on the washed laundry, whereby the residues can be unintended, i.e. inevitable or desired, so to speak as finishing, for example optical brighteners, softeners, etc. The changes of the textile substance itself can result in a raising. This can either mean that the textile becomes more harsh in feel or fluffier. Textiles which become harsher only have little influence on the skin. Whereas the change to a fluffier textile has positive effects on the skin as there are so-called 'distance holders' formed on the textile surface, which prevents an early sticking of the textiles to a perspirating skin. This increases the wear comfort. Inevitable residues on the washed laundry can be caused by wear (this is not important), the washing water and the detergent. Within the detergents only the surfactants and alkalines are of interest. Desired residues are for example optical brighteners to increase the degree of whiteness, softeners, finishing baths (starch), scents and water-repellent finishes. Regarding special cases like for example flame-retardant finishes, antistatic additives and antimicrobial effects, there is only little experience available so far.

Treatment of childhood eczema

Eczema in childhood is almost always atopic eczema, a common disease with huge impact on the quality of life of the child and family. Although atopic eczema constitutes part of the atopic syndrome, avoidance of allergens is never enough for disease control. Treatment of eczema in childhood has the same components as in adults. Emollients constitute the preventive background therapy in all stages of eczema, and topical corticosteroids are still the mainstay of treatment. Infectious exacerbation may require the use of a short course of topical or systemic antimicrobials. UV phototherapy should be considered as an adjunctive treatment to assist topical corticosteroids after an acute exacerbation of the disease. Cyclosporine can also be used in the treatment of childhood eczema in severe cases. Maternal allergen avoidance for disease prevention, oral antihistamines, Chinese herbs, dietary restriction in established atopic eczema, homeopathy, house-dust mite reduction, massage therapy, hypnotherapy, evening primrose oil, emollients, and topical coal tar are other temporarily used treatment modalities, without, however, firm evidence of efficacy from proper controlled trials. Calcineurin inhibitors constitute a new generation of drugs for both adult and childhood eczema already marketed in some countries. It is postulated that they will replace topical corticosteroids as first-line treatment of eczema.

Infectious threats from exotic pets: dermatological implications

Zoonoses are diseases that can be transmitted from animals to humans. More than 250 distinct zoonoses have been described in the literature. It is estimated that 56% of United States households contain at least one pet, and although considerable research has been performed regarding the more common household animals including dogs, cats, small birds, and rodents, surprisingly little is known about the zoonotic hazards of owning the more exotic pets. According to the 1997 USPHS/IDSA Report on the Prevention of Opportunistic Infections in Persons Infected with Human Immunodeficiency Virus, the immunocompromised patient should avoid contact with feces-laden soil, litter boxes, reptiles, most pet birds, and any animal less than 6 months old . It has also been documented that because of their inquisitive nature, children are at even higher risk for infection from animals than adolescents or immunocompetent adults. In this article the authors have reviewed the available data regarding hazards associated with the hedgehog, flying squirrel, iguana, chinchilla, and cockatoo. With the growing popularity of such exotic pets, further observation and research is warranted. Physicians need to be aware of the possibility of zoonotic disease related to exotic pet ownership, and they should address this issue when obtaining a history and formulating a differential diagnosis of cutaneous lesions suggestive of such illnesses.

Tick-borne infections

Ticks, obligate, blood-sucking members of the order Acarina and class Arachnida, are the most common agents of vector-borne diseases in the United States. Ticks play an important role in transmitting viruses, bacteria, spirochetes, parasites, and rickettsia. This article reviews the epidemiology, microbiology, diagnosis, and treatment of the major tick-borne diseases in the United States.