Papulopustular demodicosis: a case report

Successful treatment of ivermectin refractory demodicosis with isotretinoin and permethrin cream

These guidelines were written by an international group of specialists with the aim to provide veterinarians with current recommendations for the diagnosis and treatment of canine demodicosis. Published studies of the various treatment options were reviewed and summarized. Where evidence in form of published studies was not available, expert consensus formed the base of the recommendations. Demodicosis can usually be diagnosed by deep skin scrapings or trichograms; in rare cases a skin biopsy may be needed for diagnosis. Immune suppression due to endoparasitism or malnutrition in young dogs and endocrine diseases, neoplasia and chemotherapy in older dogs are considered predisposing factors and should be diagnosed and treated to optimize the therapeutic outcome. Dogs with disease severity requiring parasiticidal therapy should not be bred. Secondary bacterial skin infections frequently complicate the disease and require topical and/or systemic antimicrobial therapy. There is good evidence for the efficacy of weekly amitraz rinses and daily oral macrocyclic lactones such as milbemycin oxime, ivermectin and moxidectin for the treatment of canine demodicosis. Weekly application of topical moxidectin can be useful in dogs with milder forms of the disease. There is some evidence for the efficacy of weekly or twice weekly subcutaneous or oral doramectin. Systemic macrocyclic lactones may cause neurological adverse effects in sensitive dogs, thus a gradual increase to the final therapeutic dose may be prudent (particularly in herding breeds). Treatment should be monitored with monthly skin scrapings and extended beyond clinical and microscopic cure to minimize recurrences.

Topical Therapy in Ulcerative Colitis: Always a Bridesmaid but Never a Bride?

Scabies is a contagious parasitic dermatitis that is a significant cause of morbidity, especially outside of the United States. Scabies is diagnosed most often by correlating clinical suspicion with the identification of a burrow. Although scabies should be on the differential for any patient who presents with a pruritic dermatosis, clinicians must consider a wide range of diagnostic possibilities. This approach will help make scabies simultaneously less over- and underdiagnosed by clinicians in the community. Atypical or otherwise complex presentations may necessitate the use of more definitive diagnostic modalities, such as microscopic examination of KOH prepared skin scrapings, high-resolution digital photography, dermoscopy, or biopsy. Scabies therapy involves making the correct diagnosis, recognizing the correct clinical context to guide treatment of contacts and fomites, choosing the most effective medication, understanding how to use the agent properly, and following a rational basis for when to use and reuse that agent. Although the development of new therapeutic agents is always welcome, tried and true treatments are still effective today. Permethrin is the gold standard therapy, with malathion being an excellent topical alternative. Ivermectin is an effective oral alternative that is especially useful in crusted scabies, patients who are bed ridden, and in institutional outbreaks. Despite the availability of effective therapeutics, treatment failures still occur, mostly secondary to application error (ie, failure to treat the face and scalp or close contacts, failure to reapply medication) or failure to decontaminate fomites. Because increasing resistance to scabies treatments may be on the horizon, we propose that standard of care for scabies treatment should involve routine treatment of the scalp and face and re-treating patients at day 4 on the basis of the scabies life cycle to ensure more efficient mite eradication. Practitioners should attempt to treat all close contacts simultaneously with the source patient. To eradicate mites, all fomites should be placed in a dryer for 10 minutes on a high setting, furniture and carpets vacuumed, and nonlaunderables isolated for a minimum of 2 days, or, for those who wish to be rigorous, 3 weeks.

Bacterial vaginosis (BV) is associated with a state of vaginal dysbiosis typically involving depletion of otherwise dominant populations of Lactobacillus. The causes of this microbial succession are not known; there may be multiple causes. Standard treatment includes oral metronidazole, which typically restores Lactobacillus species to dominance. However, recurrence rates are high; recurrent BV patients recur 3–4 times annually and are often refractory to treatment. Our previous qPCR-based study of recurrent BV patients pointed to putatively more virulent species of Gardnerella that were associated with refractory responses to oral metronidazole, and less robust recovery of Lactobacillus species associated with recurrence after an initial period of remission. However, these associations did not account for outcomes in all patients, suggesting that other bacterial species were involved. In this follow-up study, we sequenced the V4 domain of 16S rRNA sequences of 41of these same patients pre- and posttreatment. Overall compositions among pretreatment clinical outcome groups were not different, although alpha diversity significantly decreased: refractory > recurrent > remission. Combinations of key species were associated with and prognostic for outcome. Higher pretreatment abundance of Megasphaera lornae together with lower abundance of Gardnerella Gsp07 and Finegoldia magna predicted long term remission after oral metronidazole. Furthermore, a subset of refractory patients that did not have high levels of Gardnerella Gsp07, instead had elevated levels of alternative species including Atopobium vaginae, Mageeibacillus indolicus (BVAB3), and Prevotella timonensis. Patients who recurred after transient remission had elevated abundance of species including Atopobium vaginae, Gardnerella, and Aerococcus christensenii, compared to long-term remission patients. Core bacterial species among refractory patients did not change in abundance after metronidazole, suggesting resistance or tolerance, in contrast to the loss in abundance of the same species among recurrent or remission patients. These findings have potential prognostic and therapeutic implications.

Demodex mites seem to serve as a pathogenic trigger in many Demodex-associated diseases such as rosacea. In facial skin of patients with rosacea significantly higher numbers of Demodex mites have been shown compared with healthy controls. Reflectance confocal microscopy (RCM) allows the detection and quantification of Demodex mites in vivo noninvasively. It is hypothesized that a reduction of Demodex mites under rosacea therapy can be monitored by RCM. To use RCM to monitor the density of Demodex mites in patients with rosacea before and after treatment. In 25 patients with facial rosacea RCM was performed before and after therapy. Mosaics of 5 × 5 mm(2) and 8 × 8 mm(2) were scanned, and the total numbers of mites per follicle and per area were counted, along with the number of follicles per area. In all patients Demodex folliculorum could be detected and quantified using RCM. RCM showed significant differences pre- and post-treatment (P = 0.0053 for 5 × 5 mm(2) and P < 0.001 for 8 × 8 mm(2)). The mean numbers of mites per follicle were 0.63 (range 0.16-2.28) per 8 × 8 mm(2) area and 0.70 (range 0.11-2.20) per 5 × 5 mm(2) area before treatment, and 0.41 (range 0.074-1.75) and 0.51 (range 0.094-1.70), respectively, after treatment. The corresponding mean numbers of mites were 155 (range 45-446) and 86.2 (range 12-286), respectively, before treatment and 96.2 (range 18-363) and 58.5 (range 12-230), respectively, after treatment. By RCM, a reduction in the density of Demodex mites in facial skin of patients with rosacea under therapy, correlating to clinical improvement, can be quantified and monitored noninvasively. Possible reasons for this therapeutic effect are discussed.

BackgroundBacterial vaginosis (BV) is a common condition that is associated with preterm birth and acquisition of complex communities of vaginal bacteria that include several fastidious species. Treatment of BV in pregnancy has mixed effects on the risk of preterm delivery, which some hypothesize is due to variable antibiotic efficacy for the fastidious bacteria. Both oral and intravaginal metronidazole can be used to treat bacterial vaginosis in pregnancy, but little is known about the impact of different routes of antibiotic administration on concentrations of fastidious vaginal bacteria.MethodsThis was a sub-study of a larger randomized trial of oral versus vaginal metronidazole for treatment of BV in pregnancy. Fifty-three women were evaluated, including 30 women who received oral metronidazole and 23 who received intravaginal metronidazole. Bacterial taxon-specific quantitative PCR assays were used to measure concentrations of bacterial vaginosis associated bacterium (BVAB) 1, 2, and 3, Gardnerella vaginalis, Atopobium species, Leptotrichia/Sneathia species, Megasphaera species, and Lactobacillus crispatus before and after antibiotic treatment.ResultsConcentrations of Leptotrichia and Sneathia spp. and the fastidious Clostridia-like bacterium designated BVAB1 decreased significantly with oral (p = .002, p = .02) but not vaginal therapy (p = .141, p = .126). The fastidious bacterium BVAB3 did not significantly decrease with either treatment. Concentrations of Atopobium spp., reportedly resistant to metronidazole in vitro, dropped significantly with oral (p = .002) and vaginal (p = .001) treatment. There was no significant difference in the magnitude of change in bacterial concentrations between oral and vaginal treatment arms for any of the bacterial species. Lactobacillus crispatus concentrations did not change.ConclusionBoth oral and vaginal metronidazole therapy in pregnant women result in a significant decrease in concentrations of most BV-associated anaerobic bacteria, with the exception that Leptotrichia, Sneathia and BVAB1 do not significantly decrease with vaginal metronidazole therapy. These data suggest that the route of antibiotic administration has a minor impact on bacterial eradication in pregnant women with BV.Trail RegistrationThis trial is registered with ClinicalTrials.gov, number NCT00153517

Background: Pain after open “Morgan-Milligan” hemorrhoidectomy is a significant problem both for the patient and the surgeon. It increases analgesics need, prolongs the hospital stay, delay first act, hindered early return to usual daily activities and causes a significant anxiety to the patient and family. Aim of the Study: To evaluate effectiveness of oral Metronidazole therapy in the decreasing pain after open hemorrhoidectomy. Patients and Methods: A prospective controlled study was set in the Department of Surgery/Al-Yarmouk Teaching Hospital. The study included adult patients who undergone elective opened “Morgan-Milligan” hemorrhoidectomy for grade III and IV disease. Data collection was completed over the period from the 1st of June 2017 to 15th of January 2019. The total number of patients after exclusion was 64 patients (32 patients in each group). Patients who are discharged in the first operative day were allocated in to two groups; those who received oral Metronidazole course (group A; study group) and those who did not received the therapy (group B; control group). The main parameter studied was pain. Other parameters include frequency of analgesic doses required, time for first bowel motion, time for return for usual daily activities and evidences of Surgical Site Infection. The method for pain assessment was Visual Analogue Scale (VAS) of 10 grades. A scale sheet was supplied for each patient (in native language) and patients were informed clearly how to fill the required information. At the end of the first week, the attendance of the patients and delivery of the VAS sheet is considered the date for termination of assessment. Patients who are lost to follow up or discontinued therapy due to drug intolerance, were excluded from analysis. Data tabulated and appropriately displayed and statistically analyzed using Statistical Package for Social Sciences (SPSS) version 25. A P-Value less than 0.05 was considered significant. Ethical aspects and official approval were appropriately considered. Results: The overall age range was 18 - 55 years (a mean of 32.37 years and a standard deviation of±10.06 years). Female gender predominates in both groups (22 in group A, 18 in group B). The majority in both group A and B have Grade III hemorrhoid (81.3% and 87.5% respectively). There were no statistically significant differences between the two groups regarding age and gender. Postoperatively, the mean of VAS in the 1st, 3rd, 7th day, and on the 1st bowel motion was significantly lower in group A patients compared to those in Group B (5.46 versus 6.71, p = 0.011; 5.31 versus 7.81, p = 0.001; 4.46 versus 6.25, P = 0.001; and 4.06 versus 6.56, p = 0.001; respectively). There was no statistically significant difference (p = 0.104) between study groups in mean of VAS in the 2nd day. The mean of doses of analgesia required in the 1st, 3rd, 7th day, and on the 1st bowel motion was significantly lower in group A patients compared to those in Group B (2.75 versus 3.37, p = 0.001; 2.75 versus 3.37, p = 0.002; 2.37 versus 3, p = 0.016; and 3.43 versus 3.93, p = 0.001; respectively). Again; no statistically significant difference (p = 0.162) between study groups regarding mean doses of analgesia on the 2nd day. No statistically significant difference (p = 0.11) was reported between study groups regarding mean time for 1st bowel motion. Returning to usual daily activities was significantly earlier in group A patients compared with patients in Group B (5.68 versus 7.12 days, p = 0.028). At the end of first week; a total of 7 (11%) patients demonstrated signs of Surgical Site Infection. This was statistically insignificant when compared between both groups (p = 0.229). Conclusion: There are evidences that oral Metronidazole therapy after open hemorrhoidectomy can play a role in reduction of pain intensity.

PurposeOral metronidazole therapy is the standard of care for bacterial vaginosis (BV), yet it has alarming rates of recurrence and refractory responses among recurrent BV (RBV) patients. This study addresses whether high dose vaginal metronidazole therapy (HDM) is beneficial in RBV patients who fail after standard of care (SOC) therapy, whether diagnostic test scores proximal to the HDM predict clinical outcome, and whether menses, coitus, or race influences therapy outcome.Patients and methodsA total of 90 patients with RBV were given SOC and tracked 74 for up to 9 months. Refractory or recurrent patients (57) with symptomatic BV were given HDM and followed for up to 8 months. Patients were evaluated by Amsel criteria, Nugent score, and a qPCR assay that assesses the Lactobacillus content.ResultsHDM achieved at least short-term remission in 68% of the patients who were refractory to or recurred after SOC and provided a 10-day increase in the mean duration of remission among patients who eventually recurred (p=0.027). Patients with prolonged dysbiosis (pH >5 or Amsel 4) before symptomatic recurrence were more likely to recur after subsequent HDM. Most recurrence happened within 10 days of menses, but sex in this cohort was not associated with clinical outcome. Mean diagnostic BV scores of African American patients in remission were inferior to scores of a small cohort of Caucasian patients in remission.ConclusionEncouraging results obtained with HDM justify a prospective, randomized study to determine if follow-up HDM is beneficial among a broader cohort of women failing conventional oral metronidazole therapy.

Background: Pain after open “Morgan-Milligan” hemorrhoidectomy is a significant problem both for the patient and the surgeon. It increases analgesics need, prolongs the hospital stay, delay first act, hindered early return to usual daily activities and causes a significant anxiety to the patient and family. Aim of the study: To evaluate effectiveness of oral Metronidazole therapy in the decreasing pain after open hemorrhoidectomy. Patients and methods: A prospective controlled study was set in the Department of Surgery/Al-Yarmouk Teaching Hospital. The study included adult patients who undergone elective opened “Morgan-Milligan” hemorrhoidectomy for grade III and IV disease. Data collection was completed over the period from the 1st of June 2017 to 15th of January 2019. The total number of patients after exclusion was 64 patients (32 patients in each group). Patients who are discharged in the first operative day were allocated in to two groups; those who received oral Metronidazole course (group A; study group) and those who did not received the therapy (group B; control group). The main parameter studied was pain. Other parameters include frequency of analgesic doses required, time for first bowel motion, time for return for usual daily activities and evidences of Surgical Site Infection. The method for pain assessment was Visual Analogue Scale (VAS) of 10 grades. A scale sheet was supplied for each patient (in native language) and patients were informed clearly how to fill the required information. At the end of the first week, the attendance of the patients and delivery of the VAS sheet is considered the date for termination of assessment. Patients who are lost to follow up or discontinued therapy due to drug intolerance, were excluded from analysis. Data tabulated and appropriately displayed and statistically analyzed using Statistical Package for Social Sciences (SPSS) version 25. A P-Value less than 0.05 was considered significant. Ethical aspects and official approval were appropriately considered. Results: The overall age range was 18 - 55 years (a mean of 32.37 years and a standard deviation of ± 10.06 years). Female gender predominates in both groups (22 in group A, 18 in group B). The majority in both group A and B have Grade III hemorrhoid (81.3% and 87.5% respectively). There were no statistically significant differences between the two groups regarding age and gender. Postoperatively, the mean of VAS in the 1st, 3rd, 7th day, and on the 1st bowel motion was significantly lower in group A patients compared to those in Group B (5.46 versus 6.71, P= 0.011; 5.31 versus 7.81, P= 0.001; 4.46 versus 6.25, P= 0.001; and 4.06 versus 6.56, P= 0.001; respectively). There was no statistically significant difference (P = 0.104) between study groups in mean of VAS in the 2nd day. The mean of doses of analgesia required in the 1st, 3rd, 7th day, and on the 1st bowel motion was significantly lower in group A patients compared to those in Group B (2.75 versus 3.37, P= 0.001; 2.75 versus 3.37, P= 0.002; 2.37 versus 3, P= 0.016; and 3.43 versus 3.93, P= 0.001; respectively). Again; no statistically significant difference (P = 0.162) between study groups regarding mean doses of analgesia on the 2nd day. No statistically significant difference (P= 0.11) was reported between study groups regarding mean time for 1st bowel motion. Returning to usual daily activities was significantly earlier in group A patients compared with patients in Group B (5.68 versus 7.12 days, P= 0.028). At the end of first week; a total of 7 (11%) patients demonstrated signs of Surgical Site Infection. This was statistically insignificant when compared between both groups (P = 0.229). Conclusions: There are evidences that oral Metronidazole therapy after open hemorrhoidectomy can play a role in reduction of pain intensity.

Comparison of oral and vaginal metronidazole therapy for nonspecific bacterial vaginosis.

To compare the efficacy of oral versus vaginal metronidazole treatment in pregnant women with bacterial vaginosis, and to compare cytokine profiles (interleukin-1beta, -6, and -8) in the cervical secretions of these women before and after treatment. Pregnant women with bacterial vaginosis diagnosed both by Gram stain and clinical criteria were randomized to receive oral (n=52) or vaginal (n=50) metronidazole therapy. Cervical specimens for cytokine analysis and vaginal fluid for evaluation of bacterial vaginosis were obtained at baseline and 4 weeks after treatment. There was no significant difference in therapeutic cure rates (defined as a Gram stain score of 0-3 and the absence of all four clinical signs of bacterial vaginosis) between the two groups (71% and 70% for the oral and vaginal groups, respectively, P=1.0). Cervical levels of interleukin-1beta, -6, and -8 were significantly lower after treatment among the 72 women cured of bacterial vaginosis (P<.001, P=.001, and P=.02, respectively) but not among women who failed to respond to therapy. For interleukin-1beta and -6, a significant decrease in cytokine level was observed in both the oral and vaginal treatment groups. One week of oral metronidazole and 5 days of intravaginal metronidazole are equally efficacious for treatment of bacterial vaginosis during pregnancy. The decrease in cervical interleukin-1beta, -6, and -8 levels among women who established a normal flora after treatment but not among those with persistent bacterial vaginosis suggests a direct linkage between vaginal flora abnormalities and elevated cervical levels of interleukin-1beta, -6, and -8.

Cold atmospheric plasma reduces demodex count on the face comparably to topical ivermectin, as measured by reflectance confocal microscopy.

We wished to determine recurrences of bacterial vaginosis (BV) after treatment over the course of 12 months and to establish factors associated with recurrence. Women with symptomatic BV (a Nugent score [NS] of 7-10 or of 4-6 with >or=3 Amsel criteria) were enrolled. BV was treated with 400 mg of oral metronidazole twice a day for 7 days. Participants completed a questionnaire and vaginal swabs were collected at 1, 3, 6, and 12 months; the study end point was an NS of 7-10. A total of 121 (87%) women with an NS of 7-10 and 18 (13%) with an NS of 4-6 and >or=3 Amsel criteria were enrolled; 130 (94%) returned >or=1 vaginal samples. Sixty-eight women (58% [95% confidence interval {CI}, 49%-66%]) had a recurrence of BV (NS 7-10), and 84 (69% [95% CI, 61%-77%]) had a recurrence of abnormal vaginal flora (NS 4-10) by 12 months. A past history of BV, a regular sex partner throughout the study, and female sex partners were significantly associated with recurrence of BV and abnormal vaginal flora by multivariate analysis; the use of hormonal contraception had a negative association with recurrence. Current recommended treatment is not preventing the recurrence of BV or abnormal vaginal flora in the majority of women; factors associated with recurrence support a possible role for sexual transmission in the pathogenesis of recurrent BV.

Bacterial vaginosis (BV) treatment failures and recurrences are common. To identify features associated with treatment response, we compared vaginal microbiota and host ectocervical transcriptome before and after oral metronidazole therapy. Women with BV (Bronx, New York and Thika, Kenya) received 7 days of oral metronidazole at enrollment (day 0) and underwent genital tract sampling of microbiome (16S ribosomal RNA gene sequencing), transcriptome (RNAseq), and immune mediator concentrations on day 0, 15, and 35. Bronx participants were more likely than Thika participants to clinically respond to metronidazole (19/20 vs 10/18, respectively, P = .0067) and by changes in microbiota composition and diversity. After dichotomizing the cohort into responders and nonresponders by change in α-diversity between day 35 and day 0, we identified that transcription differences associated with chemokine signaling (q = 0.002) and immune system process (q = 2.5 × 10-8) that differentiated responders from nonresponders were present at enrollment. Responders had significantly lower levels of CXCL9 in cervicovaginal lavage on day 0 (P < .007), and concentrations of CXCL9, CXCL10, and monocyte chemoattractant protein 1 increased significantly between day 0 and day 35 in responders vs nonresponders. Response to metronidazole is characterized by significant changes in chemokines and related transcripts, suggesting that treatments that promote these pathways may prove beneficial.