Pain related to maggot debridement therapy.

OBJECTIVE: To summarise our experience with maggot debridement therapy (MDT) in relation to pain observed in patients treated in 16 departments and units of the Hadassah Hospital in Jerusalem, Israel. METHOD: A secondary analysis of data from 435 patients. Maggots were either placed directly on the wound using a cage-like dressing (DA), or they were applied to the wound encased in a previously prepared hermetic tea-bag like pouch (TBA). During each treatment, patients were asked whether they felt any difference in the level of pain before and during MDT treatment. RESULTS: Overall, 165 patients (38%) reported increased pain during MDT. Seventeen patients (41%), who were treated with the TBA technique, and 148 patients (38%), who were treated with the DA technique, reported increased pain and were treated with analgesics before or during MDT. In five patients, the treatment had to be discontinued due to uncontrolled pain during MDT. Pain control measures were undertaken in patients who were already in intense pain prior to the initiation of MDT and in those patients who reported intense pain during DA treatment. The measures included shorter periods of application of maggots, use of the TBA rather than DA technique, and applying relatively small maggots as well as a smaller number of maggots during an MDT session. In patients who continued reporting intense pain, systemic analgesic medications and peripheral nerve blocks were used. CONCLUSION: Since a full debridement requires an average of 2-3 maggot cycles, which last 3-5 days, and since a large percentage of patients treated with MDT complain of pain that may last throughout the therapy period, it is deemed worthwhile and even essential to titrate analgesics as needed and be prepared to treat patients even with potent analgesics, such as opioids. In cases when pain is intense and uncontrolled with systemic medications, peripheral nerve blocks should be considered. DECLARATION OF INTEREST: There were no external sources of funding for this study. The authors have no conflicts of interest to declare.

The use of maggot debridement therapy in the treatment of chronic wounds in hospitalised and ambulatory patients.

OBJECTIVE: To summarise our experience of the use of medicinal maggots for the debridement of necrotic chronic wounds and to try and identify prognostic factors for debridement success and associated pain. METHOD: During the years 1996­2009, 723 wounds of 435 patients (180 females and 255 males) were treated with maggot debridement therapy (MDT) in 16 departments and units of the Hadassah Hospital in Jerusalem, Israel. Overall, 261 patients were treated during hospitalisation, while 174 were treated as ambulatory patients. In 90.5% of the patients the wounds were located on the leg, but only 48.0% had diabetic foot ulcers. The wound duration range from one to 240 months (mean=8.9; median=4 months). Sterile maggots of the green bottle fly, Lucilia sericata, were used for MDT. In 90.6% of the cases, maggots were placed directly on the wound using a cage-like dressing and left for 24 hours, while in 9.4% of the patients maggots concealed in a tea-bag like polyvinyl netting were used. The concealed maggots were left on the wound for 2­3 days. RESULTS: The number of treatments was 1­48 (mean=2.98; median=2) and the duration of the treatment varied between one and 81 days (mean=4.65; median=3). In 357 patients (82.1%) complete debridement of the wound was achieved, while in 73 patients (16.8%) the debridement was partial and in five (1.1%) it was ineffective. Increased pain or discomfort during MDT were reported in 38% of the patients. CONCLUSION: MDT is a very safe, simple and effective treatment modality for chronic wounds in ambulatory and hospitalised patients. DECLARATION OF INTEREST: There were no external sources of funding for this study. The authors have no additional conflicts of interest to declare.

High prevalence of malignant melanoma in Israeli patients with Parkinson's disease.

The risk of melanoma is higher in patients with Parkinson's disease (PD) than in the general population. Whether the association is disease related or treatment related is unclear. The objective of this study was to assess melanoma prevalence in PD patients in Israel using active dermatologic screening. Consecutive patients with idiopathic PD were recruited by 12 Israeli centers. A movement disorder specialist assessed the severity of PD and obtained a medical, neurological, and medication history. Subsequently, a dermatologist assessed melanoma risk factors, recorded a dermatologic history, proactively performed a whole-body skin examination, and biopsied suspicious skin lesions. Of the enrolled patients (n = 1,395, mean age 69.5 ± 10.6 years, mean PD duration 7.3 ± 6.0 years), 95.3% were treated with dopaminergic agents. Biopsies revealed 8 patients with melanoma in situ and 1 with invasive malignant melanoma; 14 patients reported a melanoma prior to enrollment. The observed 5-year limited duration prevalence of melanoma in PD patients was 4.4 times greater (95% CI 2.6-7.6) than expected from melanoma prevalence in an age- and sex-matched cohort from the Israel National Cancer Registry. The increase was accounted for by an elevated prevalence of melanoma in situ [relative risk 12.5 (95% CI 6.7-23.2)]. Occurrence of melanoma did not correlate with levodopa therapy or time of onset of PD. Melanoma prevalence in PD patients was higher than expected in the general Israeli population. This was not related to levodopa treatment. PD patients should be actively screened for melanoma on a routine basis.

Tropism of herpes simplex virus type 1 to nonmelanoma skin cancers.

BACKGROUND: Current treatments for nonmelanoma skin cancer include surgery, Mohs micrographic surgery, radiation, cryosurgery, photodynamic therapy, local chemotherapy and application of immunomodulators such as imiquimod. However, all have a 5-year recurrence rate of 1-40%. Gene therapy for the treatment of skin cancers is a promising new approach, as delivery of the vectors to the skin is simple and safety issues can be properly addressed. OBJECTIVES: To develop an ex-vivo organ culture system for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) tumours, and to test the feasibility of applying oncolytic viruses to these tumours. METHODS: We first optimized conditions for the maintenance of BCC and SCC tissues in organ culture, and demonstrated viability of the tissues ex vivo for 3-7 days. The tropism of two potential oncolytic viral vectors, herpes simplex virus type 1 (HSV-1) and adenovirus (AD), was next evaluated. RESULTS: Immunohistological analysis revealed that HSV-1 targeted tumour cells that expressed p63 and did not express keratin 15 or keratin 14 markers of keratinocytes. Further examination indicated that uninfected BCC and SCC tissues express two isoforms of p63 mRNA, and HSV-1 infection specifically enhanced expression of the TAp63 isoform. Furthermore, following infection, both HSV-1 and AD induced apoptosis in the BCC and SCC cells as indicated by the induction of activated caspase-3. CONCLUSIONS: The results indicated a specific pattern of viral tropism to skin cancer cells that are critical for maintenance of the tumour. This new experimental system should aid in the analysis of new therapeutic modalities, such as oncolytic viruses, for future treatment of these skin tumours.

Treatment of scabies infestations.

Scabies is an intensely pruritic disorder induced by an immune allergic response to infestation of the skin by the mite Sarcoptes scabiei. The biology of the mite, the clinical aspects and diagnosis of scabies infestations as well as the treatment of choice with 5% permethrin dermal cream and the use of scabicides based on other chemical substances are reviewed.

Maggot débridement therapy in outpatients.

OBJECTIVE: To identify the benefits, risks, and problems associated with outpatient maggot therapy. DESIGN: Descriptive case series, with survey. SETTING: Urban and rural clinics and homes. PARTICIPANTS: Seven caregivers with varying levels of formal health care training and 21 ambulatory patients (15 men, 6 women; average age, 63 yr) with nonhealing wounds. INTERVENTION: Maggot therapy. MAIN OUTCOME MEASURE: Therapists' opinions concerning clinical outcomes and the disadvantages of therapy. RESULTS: More than 95% of the therapists and 90% of their patients were satisfied with their outpatient maggot débridement therapy. Of the 8 patients who were advised to undergo amputation or major surgical débridement as an alternative to maggot débridement, only 3 required surgical resection (amputation) after maggot therapy. Maggot therapy completely or significantly débrided 18 (86%) of the wounds; 11 healed without any additional surgical procedures. There was anxiety about maggots escaping, but actual escapes were rare. Pain, reported by several patients, was controlled with oral analgesics. CONCLUSIONS: Outpatient maggot débridement is safe, effective, and acceptable to most patients, even when administered by nonphysicians. Maggot débridement is a valuable and rational treatment option for many ambulatory, home-bound, and extended care patients who have nonhealing wounds.

Bullous erysipelas: A retrospective study of 26 patients.

BACKGROUND: Erysipelas is a superficial form of cellulitis caused by a variety of microbes, and it responds to antibiotic treatment. During the past few years we treated several patients with a bullous form of erysipelas involving the lower legs. We believe their disease had a more protracted course than patients with nonbullous erysipelas. OBJECTIVE: We studied bullous erysipelas by conducting a retrospective analysis of 26 patients with bullous erysipelas of the legs treated by the authors during a 5-year period. METHODS: We conducted a retrospective review of the records of all patients with a diagnosis of bullous erysipelas who were treated at the Department of Dermatology, Hadassah Medical Center, Jerusalem, between the years 1992 and 1996. Data regarding patients with nonbullous erysipelas were obtained from the medical center's computerized data pool. RESULTS: A total of 26 cases of bullous erysipelas were found, comprising 22 women and 4 men whose ages ranged from 28 to 87 (mean, 58.8) years. The average hospital stay was 20.57 days (range, 12 to 46 days). The average hospital stay for patients with nonbullous erysipelas and cellulitis treated in the same department by the authors during the study period was 10.6 days (range, 2 to 54 days). CONCLUSION: Bulla formation is a complication of erysipelas, seen in our series in 5.2% of the patients (26 of 498 admissions for erysipelas and cellulitis). The course of the disease is protracted, requiring longer medical attention.

Maggot therapy for the treatment of intractable wounds.

BACKGROUND: Fly maggots have been known for centuries to help debride and heal wounds. Maggot therapy was first introduced in the USA in 1931 and was routinely used there until the mid-1940s in over 300 hospitals. With the advent of antimicrobiols, maggot therapy became rare until the early 1990s, when it was re-introduced in the USA, UK, and Israel. The objective of this study was to assess the efficacy of maggot therapy for the treatment of intractable, chronic wounds and ulcers in long-term hospitalized patients in Israel. METHODS: Twenty-five patients, suffering mostly from chronic leg ulcers and pressure sores in the lower sacral area, were treated in an open study using maggots of the green bottle fly, Phaenicia sericata. The wounds had been present for 1-90 months before maggot therapy was applied. Thirty-five wounds were located on the foot or calf of the patients, one on the thumb, while the pressure sores were on the lower back. Sterile maggots (50-1000) were administered to the wound two to five times weekly and replaced every 1-2 days. Hospitalized patients were treated in five departments of the Hadassah Hospital, two geriatric hospitals, and one outpatient clinic in Jerusalem. The underlying diseases or the causes of the development of wounds were venous stasis (12), paraplegia (5), hemiplegia (2), Birger's disease (1), lymphostasis (1), thalassemia (1), polycythemia (1), dementia (1), and basal cell carcinoma (1). Subjects were examined daily or every second day until complete debridement of the wound was noted. RESULTS: Complete debridement was achieved in 38 wounds (88.4%); in three wounds (7%), the debridement was significant, in one (2.3%) partial, and one wound (2.3%) remained unchanged. In five patients who were referred for amputation of the leg, the extremities was salvaged after maggot therapy. CONCLUSIONS: Maggot therapy is a relatively rapid and effective treatment, particularly in large necrotic wounds requiring debridement and resistant to conventional treatment and conservative surgical intervention.

South American cutaneous leishmaniasis: report of ten cases in Israeli travelers.

BACKGROUND: Cutaneous South American leishmaniasis is caused by several species of leishmaniasis. Lack of appropriate treatment may lead to mucocutaneous leishmaniasis, mainly with L. b. braziliensis and L. b. panamensis. OBJECTIVE: To describe the clinical findings of Israeli travelers infected with cutaneous South American leishmaniasis and to draw attention to this problem. SUBJECTS: Ten patients were interviewed, examined and treated. RESULTS: Twenty-two lesions of cutaneous leishmaniasis were found, all in exposed areas. Patients were seen by an average three physicians (range 1-6) before the final diagnosis was confirmed by direct smear, after an average period of 125 days (range 88-270 days). Treatment with Pentostam was started after an average period of 134 days (range 94-275 days). All lesions healed completely, but with scarring. CONCLUSION: Travelers to endemic areas, as well as physicians, should be instructed about the potential risks and the clinical manifestations of cutaneous and mucocutaneous South American leishmaniasis. Such awareness will prevent undue delay in diagnosis and treatment.

Terra firma forme dermatosis.

New pigmented lesions with alarming properties should trigger the responsible physician to perform diagnostic procedures including biopsies, blood tests, and endocrinological evaluations. A unique pigmented dermatosis of unknown etiology, known as terra firma forme dermatosis, creates a cosmetic disturbance that might mislead experienced physicians and trigger unnecessary and expensive workups when all that is needed is a firm rubbing with 70% alcohol-impregnated applicators. We present a 17-year-old girl with such a lesion and discuss the diagnostic possibilities.

Porokeratosis of Mibelli. Overview and review of the literature.

Porokeratosis of Mibelli is an uncommon dermatosis, which may be associated with immunosuppression and may undergo malignant transformation. Due to the wide range of clinical presentations, numerous classifications have evolved, resulting in some confusion. This article examines the classification and presentation of porokeratosis and, in particular, reviews the association with immunosuppression.