Report of terbinafine resistant Trichophyton spp. in Italy: Clinical presentations, molecular identification, antifungal susceptibility testing and mutations in the squalene epoxidase gene.

BACKGROUND: Numerous reports of resistance to terbinafine in Trichophyton spp. from all over the world are arousing justified attention and concern. Point mutations in the gene that encodes the squalene epoxidase (SQLE) enzyme are responsible for these therapeutic resistances. OBJECTIVES: Primary objective of the study was to describe first isolates of Trichophyton spp. resistant to terbinafine among the patients treated between September 2019 and June 2022 at the Dermatology Units of Ospedale Maggiore Policlinico and San Bortolo Hospital. Secondary objective was to study the resistance mechanism. METHODS: Patients with confirmed Trichophyton spp. infection has been treated with systemic and topical terbinafine. Patients were then re-evaluated 12 weeks after the therapy. Patients with incomplete or absent response to terbinafine underwent a new skin scraping for direct mycological examination, new identification of dermatophyte species from culture and MALDI-TOF, molecular species identification, antifungal susceptibility testing and molecular analysis of SQLE gene. RESULTS: We identified five patients without clinical response to treatment with terbinafine. The DNA sequencing of the ITS region identified one Trichophyton rubrum and four Trichophyton indotineae. The T. rubrum strain showed minimum inhibitory concentration (MIC) (90% growth inhibition) of 4 mg/L for terbinafine. The four T. indotineae strains showed a MICs range of 0.25-4 mg/L for terbinafine. The analysis of the SQLE gene in the T. rubrum strain showed a nucleotide substitution generating a missense mutation (L393F). The SQLE gene sequencing in the T. indotineae strains showed a nucleotide substitution generating a missense mutation (F397L) in two strains, a nucleotide substitution L393S in one strain and a nucleotide substitution F415C in another strain. CONCLUSIONS: We report the first cases of terbinafine-resistant Trichophyton isolates in the Italian population. Solid antifungal management programs will be needed to promote more responsible use of antimycotics and preserve their therapeutic efficacy to control antifungal resistance.

Rosacea fulminans: two case reports and review of the literature.

Rosacea fulminans is a rare and severe inflammatory dermatosis which affects predominantly childbearing women. It is characterized by sudden onset and it usually localizes exclusively on the centrofacial areas, presenting with numerous fluctuant inflammatory nodules and papules which may coalesce. Treatment with isotretinoin in combination with topical and systemic corticosteroids is successful. Clearance of lesions may be obtained under systemic treatment with no or minimal scarring outcomes. Due to rare incidence its pathophysiological mechanisms, diagnosis and management remain controversial. We report two cases of rosacea fulminans arisen in otherwise healthy people and completely healed after treatment. Our aim is to share our experience about this disease in order to increase knowledge about its diagnosis, management and its treatment. We also make a review of the literature of this peculiar dermatosis.

Hidradenitis suppurativa in patients with Down syndrome.

Literature data about hidradenitis suppurativa (HS) in patients with Down syndrome (DS) are limited. In this retrospective study, 6 (4M/2F; mean age: 18.7 years) out of 313 patients affected by HS (1.9%) had DS. The age of appearance of HS was from 9 to 14 years. No family history of HS was present. BMI ranged from 20.1 to 29.9. In all patients, HS was located below the diaphragm. Five out of six patients were staged as Hurley II severity.

The patient journey: a voyage from diagnosis to hidradenitis suppurativa multidisciplinary unit.

BACKGROUND: Hidradenitis suppurativa (HS) is an inflammatory, recurrent and debilitating chronic skin disease that is often worsened by comorbidities, with a destructive impact on the social and working life of the patient. The low awareness of patients and clinicians regarding HS, together with weak coordination between specialists who manage the clinical care of these patients, may result in a burdening diagnostic and therapeutic delay, lowering efficacy of therapies and worsening prognosis and patients' QoL. OBJECTIVES: To rule out these critical aspects, a HS-Multidisciplinary Unit with a hierarchical organization is proposed. METHODS: Based on previously published models of a multidisciplinary unit, a hierarchical structure of a HS-dedicated multidisciplinary unit was designed. RESULTS: In this model, an operational core constituted by four healthcare professionals constantly working as team, is supported by a large panel of consultants, local dermatologists and general practitioners, helping in HS patient management. CONCLUSIONS: This standardization would imply an optimization of professional resources, an amelioration of patient's quality of life, and a shortening of patient journey.

Cutibacterium acnes (Propionibacterium acnes) and acne vulgaris: a brief look at the latest updates.

While the commensal bacterium Propionibacterium acnes (P. acnes) is involved in the maintenance of a healthy skin, it can also act as an opportunistic pathogen in acne vulgaris. The latest findings on P. acnes shed light on the critical role of a tight equilibrium between members of its phylotypes and within the skin microbiota in the development of this skin disease. Indeed, contrary to what was previously thought, proliferation of P. acnes is not the trigger of acne as patients with acne do not harbour more P. acnes in follicles than normal individuals. Instead, the loss of the skin microbial diversity together with the activation of the innate immunity might lead to this chronic inflammatory condition. This review provides results of the most recent biochemical and genomic investigations that led to the new taxonomic classification of P. acnes renamed Cutibacterium acnes (C. acnes), and to the better characterisation of its phylogenetic cluster groups. Moreover, the latest data on the role of C. acnes and its different phylotypes in acne are presented, providing an overview of the factors that could participate in the virulence and in the antimicrobial resistance of acne-associated strains. Overall, this emerging key information offers new perspectives in the treatment of acne, with future innovative strategies focusing on C. acnes biofilms and/or on its acne-associated phylotypes.

Acne across Europe: an online survey on perceptions and management of acne.

BACKGROUND: Acne is common among young people. OBJECTIVE: To describe the burden, management and sources of advice of acne in a representative sample of young people in Europe. METHODS: This cross-sectional survey was conducted in a representative sample of individuals aged 15-24 years from Belgium, Czech and Slovak Republics, France, Italy, Poland and Spain (n = 3099). RESULTS: Most individuals considered their acne (all severity stages) to be no/minor problem, although 29.7% considered it a major problem/burden. Over-the-counter (OTC) topical treatments were used more frequently than prescribed treatments. Acne was diagnosed by physicians in 47.6% of cases; other health professionals (nurses, pharmacists) or patients accounted for the remainder of diagnoses. Physicians were the source of acne information in just over one-quarter of cases (27.0%). The vast majority of advice was from friends/family and the Internet. CONCLUSION: Almost one-third of young people consider acne to be a major problem/burden. Fewer than half of acne diagnoses are made by a physician, and acne is often self-managed using OTC treatments.

Acne prevalence and associations with lifestyle: a cross-sectional online survey of adolescents/young adults in 7 European countries.

BACKGROUND: Although acne vulgaris is a common skin disorder, limited epidemiological data exist specifically for European populations. OBJECTIVE: To determine the prevalence of self-reported acne among young people in Europe and evaluate the effect of lifestyle on acne. METHODS: We conducted a cross-sectional population-based online survey in representative samples of individuals aged 15-24 years in Belgium, Czech and Slovak Republics, France, Italy, Poland and Spain (n = 10 521), identified by a quota sampling method based on age, geographic location and socio-professional category. RESULTS: The overall adjusted prevalence of self-reported acne was 57.8% (95% confidence interval 56.9% to 58.7%). The rates per country ranged from 42.2% in Poland to 73.5% in the Czech and Slovak Republics. The prevalence of acne was highest at age 15-17 years and decreased with age. On multivariate analysis, a history of maternal or paternal acne was associated with an increased probability of having acne (odds ratio 3.077, 95% CI 2.743 to 3.451, and 2.700, 95% CI 2.391 to 3.049, respectively; both P < 0.0001), as was the consumption of chocolate (OR 1.276, 95% CI 1.094 to 1.488, for quartile 4 vs. quartile 1). Increasing age (OR 0.728, 95% CI 0.639 to 0.830 for age 21-24 years vs. 15-17 years) and smoking tobacco (OR 0.705, 95% CI 0.616 to 0.807) were associated with a reduced probability of acne. CONCLUSION: The overall prevalence of self-reported acne was high in adolescents/young adults in the European countries investigated. Heredity was the main risk factor for developing acne.

Purpuric herpes zoster in patients in therapy with clopidogrel.

Clopidogrel is an adenosine diphosphate receptor antagonist used for the prevention of vascular events in patients with atherothrombotic diseases manifested by recent myocardial infarction, ischemic stroke or peripheral arterial disease. Diarrhoea, rash and pruritus are rather common side effects of clopidogrel. Other side effects include epistaxis, nausea, abdominal pain, vomiting, gastritis, gastric and duodenal ulcer. Thrombocytopenia is the most common laboratory abnormality. Leucopenia and neutropenia are rare. We report three cases of purpuric herpes zoster in patients in therapy with clopidogrel. To our knowledge, only one case of haemorrhagic herpes zoster has been published in a patient in therapy with this drug.

Treatment of mild to moderate acne with a fixed combination of hydroxypinacolone retinoate, retinol glycospheres and papain glycospheres.

AIM: A fixed combination of 0.1% hydroxypinacolone retinoate (synthetic esther of 9-cis-retinoic acid), 1% retinol in glycospheres and 2% papain in glycospheres in aqueous gel has been recently introduced into the Italian market in order to reduce the incidence and severity of irritant contact dermatitis caused by topical retinoids, without compromising their efficacy. Primary objectives of this sponsor-free, pilot, open, multicenter study were to evaluate the efficacy and tolerability of this gel in patients with comedonal-papular, mild to moderate acne of the face. METHODS: Ninety-eight Caucasian patients (28 males and 70 females), with an age ranging from 15 to 40 years, were treated with the gel once daily for 12 weeks. Acne severity and treatment efficacy were evaluated by means of the Global Acne Grading System (GAGS) and lesions count. RESULTS: Ninety-four patients were considered evaluable. A 41% mean reduction in the GAGS score was observed; a 40.8% mean reduction of total lesions was recorded; 15.3% of patients experienced mild to moderate local side effects (dryness, peeling, erythema, burning). No patients stopped the treatment because of these side effects. CONCLUSION: This study, based on a high number of evaluable patients, demonstrates that this fixed combination is an effective and safe option for the treatment of comedonal-papular, mild to moderate acne of the face. A controlled clinical study is necessary to confirm these data.

Dermatomycoses and inflammation: The adaptive balance between growth, damage, and survival.

Dermatomycosis is characterized by both superficial and subcutaneous infections of keratinous tissues and mucous membranes caused by a variety of fungal agents, the two most common classes being dermatophytes and yeasts. Overall, the stepwise process of host infection is similar among the main dermatomycotic species; however, the species-specific ability to elicit a host reaction upon infection is distinct. Yeasts such as Candida albicans elicit a relatively low level of host tissue damage and inflammation during pathogenic infection, while dermatophytes may induce a higher level of tissue damage and inflammatory reaction. Both pathogens can, however, manipulate the host's immune response, ensuring survival and prolonging chronic infection. One common element of most dermatomycotic infections is the disease burden caused by inflammation and associated signs and symptoms, such as erythema, burning and pruritus. There is a strong clinical rationale for the addition of a topical corticosteroid agent to an effective antimycotic therapy, especially in patients who present with inflammatory dermatomycoses (e.g., tinea inguinalis). In this review, we aim to compare the pathogenesis of common dermatomycotic species, including Candida yeasts (Candida albicans), dermatophytes (Trichophyton, Epidermophyton or Microsporum species), and other pathogenic yeasts (Malassezia), with a special focus on unique species-specific aspects of the respective infection processes, the interaction between essential aspects of pathogenic infection, the different roles of the host inflammatory response, and the clinical consequences of the infection-related tissue damage and inflammation. We hope that a broader understanding of the various mechanisms of dermatomycoses may contribute to more effective management of affected patients.

Citrobacter koseri folliculitis of the face.

We report a case of severe Citrobacter koseri folliculitis of the face in a boy with acne. A 15-year-old boy affected by acne was admitted because of a rash located on the face. Dermatological examination revealed two large plaques, with numerous pustules, eschars and crusts, located bilaterally and symmetrically on the cheeks. Three bacteriological examinations were positive for C. koseri. The patient was successfully treated with i.m. ceftriaxone. C. koseri is a Gram-negative, aerobic, mobile, nonsporulating bacillus belonging to the Enterobacteriaceae family. It can cause meningitis, central nervous system abscess and sepsis, almost exclusively in infants and immunocompromised hosts. Respiratory tract and urinary infections have been reported in elderly people. Furthermore, rare cases of skin infections have been described.

Cosmetics for acne: indications and recommendations for an evidence-based approach.

AIM: The aim of this review was to evaluate, by a thorough revision of the literature, the true efficacy of currently available topic and systemic cosmetic acne agents. METHODS: The efficacy of currently available cosmetic acne agents has been retrospectively evaluated via thorough revision of the literature on matched electronic databases (PubMed). All retrieved studies, either randomized clinical trials or clinical trials, controlled or uncontrolled were considered. RESULTS: Scientific evidence suggests that most cosmetic products for acne may enhance the clinical outcome. Cleansers should be indicated to all acne patients; those containing benzoyl peroxide or azelaic/salicylic acid/triclosan show the best efficacy profile. Sebum-controlling agents containing nicotinamide or zinc acetate may minimize excessive sebum production. Cosmetics with antimicrobial and anti-inflammatory substances such as, respectively, ethyl lactate or phytosphingosine and nicotinamide or resveratrol, may speed acne recovery. Topical corneolytics, including retinaldehyde/glycolic acid or lactic acid, induce a comedolytic effect and may also facilitate skin absorption of topical drugs. Finally, the use of specific moisturizers should be strongly recommended in all acne patients. CONCLUSION: Cosmetics, if correctly prescribed, may improve the performance of the therapy, whereas wrong procedures and/or inadequate cosmetics may worsen acne. Cosmetological recommendations may allow clinicians to make informed decisions about the role of various cosmetics and to indentify the appropriate indications and precautions. The choice of the most effective product should take into consideration the ongoing pharmacological therapy and acne type/severity as well.