Self-care treatment for lymphoedema of lymphatic filariasis using integrative medicine.

BACKGROUND: Lymphatic filariasis (LF) is a neglected tropical disease presenting mainly as lymphoedema (elephantiasis). At present, LF is not effectively treated. Integrative medicine (IM) treatment for lymphoedema uses a combination of Indian traditional medicine, Ayurveda, alongside yoga exercises, compression therapy, antibiotics and antifungal treatments, providing a useful combination where resources are limited and different practices are in use. OBJECTIVES: To assess the effectiveness of the IM in the existing clinical practice of lower-limb lymphoedema management and to determine whether the treatment outcomes align with the World Health Organization (WHO) global goal of LF management. METHODS: Institutional data from electronic medical records of all 1698 patients with LF between 2010 and 2019 were retrospectively analysed using pre- and post-treatment comparisons and the National Institute for Health and Care Excellence guidelines for clinical audit. The primary treatment outcomes evaluated were limb volume, bacterial entry points (BEEPs), episodes of cellulitis, and health-related quality of life (HRQoL). Secondary outcomes included the influence of the patient's sex, duration of illness, education and employment status on volume reduction. Multiple regression analysis, t-test, χ2-test, analysis of variance, Mann-Whitney U-test and the Kruskal-Wallis test were used to assess the association between IM and patients' treatment outcomes. RESULTS: Limb volume reduced by 24.5% [95% confidence interval (CI) 22.47-26.61; n = 1660] following an intensive supervised care period (mean 14.84 days, n = 1660). Limb volume further reduced by 1.42% (95% CI 0.76-2.07; n = 1259) at the first follow-up visit (mean 81.45 days), and by 2.3% between the first and second follow-up visits (mean 231.32 days) (95% CI 1.26-3.34; n = 796). BEEPs were reduced upon follow-up; excoriations (78.4%) and intertrigo (26.7%) were reduced at discharge and further improvements was achieved at the follow-up visits. In total, 4% of patients exhibited new BEEPs at the first follow-up [eczema (3.9%), folliculitis (6.5%), excoriations (11.9%) and intertrigo (15.4%); 4 of 7 BEEPs were recorded]. HRQoL, measured using the disease-specific Lymphatic Filariasis Specific Quality of Life Questionnaire, showed an average score of 73.9 on admission, which increased by 17.8 at the first follow-up and 18.6 at the second follow-up. No patients developed new cellulitis episodes at the first follow-up, and only five patients (5.3%) developed new episodes of cellulitis at the second follow-up. CONCLUSIONS: IM for lower-limb lymphoedema successfully reduces limb volume and episodes of cellulitis, and also reduces BEEPs, leading to improved HRQoL. IM aligns with the LF treatment goals of the WHO and is a low-cost, predominantly self-care management protocol. IM has the potential to change care models and improve the lives of patients with lymphoedema.

Three cases of symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) induced by proton-pump inhibitors.

Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE), previously termed drug-related baboon syndrome, is an uncommon drug eruption. It is characterized by symmetrical erythema involving the gluteal and/or inguinal area in association with one other intertriginous area in the absence of systemic involvement. It typically develops a few hours to days after drug exposure. The diagnosis is based on clinical presentation and drug history. The treatment consists mainly of withdrawal of the causative agent; corticosteroids (topical or systemic) are prescribed to accelerate the resolution. We present three cases that appeared after proton-pump inhibitors (PPIs) intake.

Symmetrical drug-related intertriginous and flexural exanthema (Baboon syndrome) associated with Infliximab: a case-based review.

BACKGROUND: SDRIFE is a rare cutaneous eruption characterized by symmetrical intertriginous dermatitis, caused by delayed Type-IV immune reaction, with several reported drug-triggers. OBJECTIVE: We present a case of SDRIFE associated with infliximab in a 70-year-old female with rheumatoid arthritis, and review cases of SDRIFE associated with TNF-inhibitors. METHODS: A literature review about SDRIFE cases associated with TNF-inhibitors was performed. Articles published in English from inception to January 6th, 2022, restricted to humans, and directly related to this review were included. RESULTS: Ours is the third reported case of SDRIFE associated with TNF-inhibitors, and second with infliximab. SDRIFE can occur anytime during treatment with TNF-inhibitors, and presents with similar clinical and histopathological features as SDRIFE secondary to other drugs. No systemic manifestations have been reported, and the rash resolves after discontinuation of the TNF-inhibitor without any long-term sequelae. CONCLUSION: SDRIFE is benign, and an accurate diagnosis and discontinuation of the responsible drug remain the cornerstone of management.

Skin areas, clinical severity, duration and risk factors of intertrigo: A secondary data analysis.

AIM: To describe the skin areas most often affected by intertrigo, the clinical severity and duration of intertrigo and possible risk factors. MATERIALS AND METHODS: Secondary analysis of data from 2013 to 2016 collected by the International Prevalence Measurement of Care Quality in Dutch hospitals, care homes and community care. RESULTS: In total, n = 7865 (mean age 80.1 years) subjects were included in this analysis. The inguinal, breast and gluteal cleft skin areas were most often affected by intertrigo. The skin was often inflamed but not eroded. Strongest associations between intertrigo at inguinal skin and diabetes mellitus (OR 1.8; 95% CI 1.1-3.1), intertrigo at sub mammary folds and urinary incontinence (OR 1.6; 95% CI 0.9-2.9) and between intertrigo at gluteal cleft and urinary incontinence (OR 2.9; 95% CI 1.4-5.2) were observed. CONCLUSION: The inguinal region, sub mammary folds and gluteal clefts are most often affected by intertrigo. Female sex, urinary incontinence and high BMI seem to enhance intertrigo risk at all of these skin areas.

Medical honey for canine nasal intertrigo: A randomized, blinded, placebo-controlled, adaptive clinical trial to support antimicrobial stewardship in veterinary dermatology.

Intertrigo is a skin fold dermatitis often requiring recurrent treatment with topical antiseptics or antibiotics, which can select antimicrobial resistance. To minimize this risk, we tested the effectiveness of medical-grade Manuka honey at treating intertrigo as compared to a placebo hydrogel. We additionally characterized the culturable microbial flora of intertrigo and recorded any adverse effect with either treatment. During this randomized, placebo-controlled, double-blinded, adaptive group-sequential trial, the owners washed the affected sites on their dog with water, dried and applied a thin film of either the honey or the placebo product once daily for 21 days. Cytological and lesional composite scores, owner-assessed pruritus, and microbial cultures were assessed prior to treatment and on Day-22. The fixed effects of time, treatment, and animal-related variables on the pruritus and on each composite score, accounting for random dog effect, were estimated separately with generalized linear mixed models for repeated count outcomes (α = 0.05). The null hypothesis of equal treatment effects was rejected at the first interim analysis. The placebo (n = 16 dogs) outperformed the medical honey (n = 13 dogs) at improving both the cytological score (Treatment×Time = -0.35±0.17; P = 0.04) and clinical score (Treatment×Time = -0.28±0.13; P = 0.04). A microbial burden score higher than 4 increased the severity of the cytological score (dichotomous score: 0.29±0.11; P = 0.01), which in turn increased the severity of the clinical score and pruritus score. For every unit increase in cytological score, the linear predictor of clinical score increased by 0.042±0.019 (P = 0.03), and the one of pruritus score increased by 0.12±0.05 (P = 0.01). However, medical honey outperformed the placebo at alleviating the dog's owner-assessed pruritus after statistically controlling for masking effects (Time = -0.94±0.24; P = 0.002; and Treatment×Time = 0.80±0.36; P = 0.04). Unilateral tests of the least-square mean estimates revealed that honey only significantly improved the pruritus (Hommel-adjusted P = 0.003), while the placebo only improved the cytological and clinical scores (Hommel-adjusted P = 0.01 and 0.002, respectively). Taken together, these results question the value of Manuka honey at treating nasal intertrigo in dogs.

Toe web intertrigo in Kaposi's sarcoma patients: a microbiological study in a large cohort of patients.

Kaposi 's sarcoma (KS) is a rare multifocal angioproliferative disease associated with human herpes virus 8 (HHV-8) infection, characterized by cutaneous nodules or plaques especially on the lower limbs. Some skin modifications, such as chronic lymphedema, plantar hyperkeratosis and interdigital desquamation, may be associated with consequent impairment of the local immunosurveillance and increased risk of some bacterial or mycotic infections. With the objective of evaluating if bacterial or mycotic infections in KS patients are supported by different microorganisms compared to control patients, we performed an observational retrospective study, comparing positive cultural swabs of interdigital intertrigo of KS patients with positive cultural swabs of interdigital intertrigo of patients admitted to our dermatologic unit during the last 10 years. One hundred KS patients and 84 control patients were admitted to this study. Some of the skin swabs from interdigital spaces were positive for more than one microorganism, and therefore we found 187 microorganisms among the KS group and 182 microorganisms in the control group. The most common microrganisms among KS patients were T. mentagrophytes (16%), S. aureus (14.9%), P. aeruginosa (13.9%), S. marcescens (5,9%), while among non-KS patients were S. aureus (26,9%), C. albicans (22%), S. agalactiae (7.7%) and E. coli (9.9%). These differences are statistically significant (p < 0.01). KS patients may be more affected by toe web intertrigo due to other bacteria and dermatophytes than the general population. During clinical examination, a careful inspection is necessary for an early diagnosis of toe web intertrigo, in order to prevent serious complications, such as cellulitis and sepsis. Consequently, a cultural examination with antibiogram is required to identify the causative agent of intertrigo and guide antimicrobial therapy.

Successful treatment of recalcitrant candidal intertrigo with Dr Michaels® (Fungatinex®) product family.

Candidal intertrigo is an infection of the skin caused by Candida albicans that typically occurs in opposing cutaneous or muco-cutaneous surfaces. Because Candidiasis requires a damaged and moist environment for infection, it typically occurs in areas of friction such as the skin folds of the body. Candidal intertrigo is often difficult to treat and results are often unsatisfactory. In addition, there is a lack of evidence-based literature supporting prevention and treatments for candidal intertrigo. The aim of the study was to evaluate the efficacy of Dr Michaels® (also branded as Fungatinex®) products in the treatment of fungal intertrigo, in 20 women and 2 men with a mean age of 72. Five patients (3 female and 2 male) had type 2 diabetes and 16 (14 female and 2 male) were obese. The patients were treated with Dr Michaels® (Fungatinex®) moisturising bar, topical ointment (twice daily application) and oral herbal formulation, PSC 200 two tablets twice daily with food. After 2 weeks of treatment, the lesions had mostly resolved in all patients with only slight erythema evident. After six weeks of treatment using the moisturising bar, topical ointment and oral herbal formulations from the Dr Michaels® (Fungatinex®) product family, the lesions had totally resolved in 18 patients, while 4 patients had to continue the therapeutic protocol for another 2 weeks. Our results demonstrate that the Dr Michaels® (Fungatinex®) complementary product family is efficacious in the treatment of recalcitrant candidal intertrigo. Furthermore, this study highlights that the Dr Michaels® (Fungatinex®) product family is fast-acting and well tolerated with no serious adverse events reported. These data have important implications for resistant cases of candidal intertrigo where traditional therapies have failed.

[Risk factors associated with leg erysipelas (cellulitis) in sub-Saharan Africa: A multicentre case-control study]. / Facteurs de risque associés à l'érysipèle de jambe en Afrique subsaharienne: étude multicentrique cas-témoins.

BACKGROUND: Acute bacterial cellulitis of the leg (erysipelas) is a common problem involving considerable morbidity in dermatology practice in Africa. Previous studies conducted in Europe and North Africa have highlighted lymphoedema and toe-web intertrigo as independent factors associated with leg erysipelas. The aim of this case-control study was to identify risk factors associated with leg erysipelas in sub-Saharan Africa, within a different socio-economic and culture context. PATIENTS AND METHODS: We conducted a prospective case-control study in hospital dermatology departments in 8 sub-Saharan African countries over a 12-month period (October 2013 to September 2014). Each case of acute leg cellulitis was matched with 2 controls for age (±5 years) and sex. We analysed the general and local factors. RESULTS: During the study period, 364 cases (223 female, 141 male) were matched with 728 controls. The mean age was 42.15±15.15 years for patients and 42.11±36 years for controls. Multivariate analysis showed the following to be independent risk factors associated with leg erysipelas in our study: obesity (odds ratio [OR]=2.82 ; 95% confidence interval: 2.11-3.76), lymphoedema (OR=3.87, 95%CI: 2.17-6.89), voluntary cosmetic depigmentation (OR=4.29, 95%CI: 2.35-7.83), neglected traumatic wound (OR=37.2, 95%CI: 24.9-57.72) and toe-web intertrigo (OR=37.86, 95%CI: 22.27-64.5). CONCLUSION: The results of this study confirms the major role of local risk factors (toe-web intertrigo, lymphoedema) previously identified in other geographical settings. However, the originality of our study consists of the identification of voluntary cosmetic depigmentation as a risk factor for leg erysipelas in sub-Saharan Africa.

[Endogenous endophthalmitis as a complication in erysipelas]. / Endophtalmie endogène compliquant un érysipèle.

BACKGROUND: Endogenous endophthalmitis is a devastating infection of the eye that leads to blindness in about two-thirds of patients. It results from the haematogenous spread of a microorganism from a focus of sepsis, mainly gastro-intestinal, genitourinary or cardiac. PATIENTS AND METHODS: We describe the case of a diabetic subject presenting endogenous endophthalmitis following erysipelas of the leg due to Streptococcus agalactiae. The outcome was favourable thanks to prompt initiation of appropriate antibiotic treatment. DISCUSSION: Endogenous endophthalmitis as a complication of a skin infection is a rare entity, with only about 30 reported cases in the literature. Awareness of this condition among dermatologists would allow prompt intervention, which is essential for sparing of the patient's eyesight.

Rapid relief of intertrigo-associated pruritus due to Candida albicans with isoconazole nitrate and diflucortolone valerate combination therapy.

A 43-year-old male, with intertrigo due to Candida albicans located at the inguinal folds and accompanied by severe pruritus, was treated with topical 1% isoconazole nitrate and 0.1% diflucortolone valerate (2 applications/day for 7 days). An improvement of pruritus was reported 2 days after the beginning of the treatment. Skin lesions improved after 3 days of treatment. Complete remission of both skin lesions and pruritus was observed at day 7. No side effects were observed.

Chronic interdigital dermatophytic infection: a common lesion associated with potentially severe consequences.

Interdigital intertrigo and onychomycosis has the potential cause of severe bacterial infectious complications with pain, mobility problems, abscess, erysipelas, cellulitis, fasciitis and osteomyelitis. In another hand, diabetic neuropathy, which affects 60-70% of those with diabetes mellitus, is one of the most troubling complications for persons with diabetes. These people are high suspecting to be infected by dermatophytic infections in interdigital spaces or onychomycosis witch are frequently induce damage to the stratum corneum, leading to bacterial proliferation and secondary infection. A patient presented with an asymptomatic warm, painless, erythematous swelling of the second left toe, which had been present for a few weeks. Clinically, the lesion was categorized as erysipelas upon an insidious abscess formation. Further investigation was undertaken to confirm the presence of diabetes. Leg erysipelas is a common affection which, according to various studies, has both local concomitants (interdigital intertrigo, lymphoedema, surgical antecedents) and/or general causes (immune suppression, diabetes, alcoholism, etc). Interdigital intertrigo, tinea pedis, and onychomycosis present as public health problems that could trigger serious deterioration in patient quality of life, due to complications induced by secondary bacterial infections.

A 3-year causative study of pompholyx in 120 patients.

OBJECTIVE: To assess the relative frequency of the different causes of pompholyx evoked in the literature. DESIGN: Prospective survey. SETTING: Clinical outpatient setting. PATIENTS: A total of 120 consecutive patients with pompholyx referred to our department from 2000 through 2003. MAIN OUTCOME MEASURES: Systematic investigation of different causes of pompholyx: fungal intertrigo, hyperhidrosis, atopy, contact eczema, and internal reactions with systematic provocation tests to metals, balsam of Peru, and food allergen when suspected. RESULTS: The present study found the following causes of pompholyx in the 120 patients: mycosis (10.0%); allergic contact pompholyx (67.5%), with cosmetic and hygiene products as the main factor (31.7%), followed by metals (16.7%); and internal reactivation from drug, food, or haptenic (nickel) origin (6.7%). The remaining 15.0% of patients were classified as idiopathic patients, but all were atopic. (Percentages do not total 100 because of rounding.) CONCLUSIONS: Our data confirm the existence of reactional pompholyx to interdigital-plantar intertrigos and endogenous reactions to metals or other allergens, but they mainly point at the unexpected importance of a so-called contact pompholyx in which cosmetic and hygiene products play a preponderant role compared with metals. The great frequency of atopic conditions, even if idiopathic pompholyx is not inferred as an equivalent of atopy, should lead to further causative investigations before undertaking more expensive or extensive treatments of refractory pompholyx.

Acute bacterial skin infections and cellulitis.

PURPOSE OF REVIEW: Acute bacterial skin infections are very common, with various presentations and severity. This review focuses on deep skin infections. We separate acute nonnecrotizing infections of the hypodermis (erysipelas), forms with abscesses or exudates and necrotizing fasciitis. These three types actually differ in risk factors, bacteriology, treatment and prognosis. RECENT FINDINGS: Leg erysipelas/cellulitis occurs in more than one person/1000/year. It remains mainly due to streptococci. Foot intertrigo is an important risk factor. Necrotizing fasciitis is much rarer and usually occurs in patients with chronic diseases. Staphylococci, especially community-acquired methicillin-resistant strains in some areas, play a growing role in the intermediate form of cellulitis with abscesses and exudates. For erysipelas or noncomplicated cellulitis, antibiotic treatment at home, when feasible, is much less expensive and as effective as hospital treatment. Intermediate cases with collections and exudates often require surgical drainage. For necrotizing fasciitis early surgery remains essential in order to decrease the mortality rate. SUMMARY: Antibiotic treatment of deep skin infections must be active on streptococci; the choice of a larger spectrum of activity depends on clinical presentation, risk factors and the burden of methicillin-resistant staphylococci in the environment.

[Factors associated with palmoplantar or plantar pompholyx: a case-control study]. / Facteurs associés à la dysidrose palmo-plantaire ou plantaire: étude cas-témoins.

BACKGROUND: Disydrosis or pompholyx is a chronic and recurrent form of dermatosis that poses a number of therapeutic issues. The etiopathology of the condition is unclear. The aim of this study was to identify factors associated with the palmoplantar and plantar dysidrosis. PATIENTS AND METHODS: This was a prospective case-control study conducted between June 2001 and February 2004 at the University Hospital of Lome (Togo). Each case (palmoplantar or plantar pompholyx) was matched for age (+/- 5 years) and sex with two controls. Examination for tinea pedis was performed in all participants (patients and controls) but mycologic culture alone was done in patients with interdigital-plantar intertrigo. RESULTS: One hundred patients with pompholyx were matched with 200 controls. Mean age was 32.8 +/- 14.8 years in the patient group and 31.4 +/- 14.8 years in the control group. For univariate analysis, the main factors associated with pompholyx were: personal atopy (OR = 12.6; CI95%: 6.4 - 25.1) and familial atopy (OR = 5.8; CI95%: 3.2 - 10.5); history of eczema (OR = 5.4; CI95%: 2.6 - 11.4); hyperhidrosis (OR=4.5; CI 95%: 5.5 - 40.7), sport (OR = 8.8; CI 95%: 3.9 - 20.8); tinea pedis (OR = 15.6; CI 95%: 7.5 - 32.9). In multivariate analysis, atopy (OR = 10.5; CI95%: 8.4 - 20.8) and tinea pedis (OR = 18; CI95%: 10.5 - 25.2) were the only factors associated with pompholyx. Trichophyton rubrum was the most common etiology of tinea pedis in both patients and controls. DISCUSSION: The results of this study show atopy and tinea pedis as factors statistically associated with palmoplantar or plantar pompholyx. However, only cohort studies can determine the precise causal relationship between tinea pedis and pompholyx.

[Intertrigo in patients with lower limb lymphedema. Clinical and laboratory correlation]. / Intertrigo em pacientes com linfedema de membro inferior. Correlação clínico-laboratorial.

Cutaneous lesions in the interdigital spaces are commonly seen in lymphedema patients and their prevention and suitable care is one of the cornerstones of any successful treatment, by preventing acute inflammations and additional worsening in limb volume and fibrosis. We obtained swab specimens from the interdigital area from 21 patients followed in the Lymphedema Unit of the Department of Vascular Surgery of the University of São Paulo; thirteen of them had lesions suggestive of tinea pedis. The pathological agent could be identified in 11 out of these 13 patients: fungal infection alone was responsible for seven lesions, Corynebacterium minutissimum for another two and both agents were isolated from two patients. Although two patients had evident clinical lesion of the skin, no fungal or bacterial species could be isolated. From the eight patients without interdigital lesions, Candida and Corynebacterium was found in one. We concluded that clinical examination has a high sensibility (84%) and specificity (91%) but the high prevalence of Corynebacterium minutissimum suggests that adequate treatment should follow careful laboratory examination.