Metronidazole Cream Research Articles

Eosinophilic folliculitis

Folliculitis was common in the era before the introduction of highly active antiretroviral therapy (HAART), with a reported incidence of 9% at one HIV clinic [1]. In a recent study [2], folliculitis was more common in HIV-infected women with lower CD4 lymphocyte counts, and was less likely to occur in women receiving HAART independent of the CD4 cell count. Histopathological findings of folliculitis in HIV-infected individuals include acute folliculitis with bacteria or yeast, perifolliculitis with lymphocytic or mixed inflammation and eosinophilic folliculitis [3]. The best characterized form of folliculitis is HIV-associated eosinophilic folliculitis (HIV-EF), a pruritic papular eruption, involving the trunk, limbs and face. An absolute or relative peripheral eosinophilia is reported in 25–50% of affected patients [4], although this can be a manifestation of advanced HIV infection [5] The aetiology of HIV-EF is unknown. The presence of Demodex mites and Pityrosporum in some biopsies has led to suggestions that a hypersensitivity reaction to these organisms may be implicated. Other organisms and even sebum has also been proposed as causative follicular antigens [4]. Immunophenotypic analysis shows a T-cell lymphocytic infiltrate with a marked CD8 cell predominance [4]. The increased expression of the cytokines IL-4 and IL-5 in skin biopsies suggests a T helper type 2 dominant immune response [6]. Patients with HIV-EF usually have CD4 lymphocyte counts of less than 250 cells/ml [7]. There are anecdotal reports without details of the clinical improvement of HIV-EF with HAART [8,9], a decrease in the rate of HIV-EF since the introduction of HAART [10], and that HIV-EF may ‘reappear’ when the CD4 cell count approaches 200 cells/ml [8,11,12]. We describe three cases of HIV-EF in the setting of immune reconstitution after HAART (the details are summarized in Table 1). In each case antiretroviral therapy had recently been instituted, with good virological control and rising CD4 lymphocyte counts. Patients presented with pruritic lesions on the chest, neck and face. One patient had a worsening of a rash that had been present for 5 months before commencing HAART, the other two patients developed a new skin rash 4 months after commencing HAART. Skin biopsies demonstrated eosinophilic folliculitis, and in addition one biopsy revealed Demodex mites and fungal spores. The treatments used with some success included topical corticosteroids, oral tetracycline and ultraviolet therapy [7,13].Table 1: Summary of cases of HIV-associated eosinophilic folliculitis.Immune reconstitution syndrome usually occurs in the first few months after the initiation of HAART. The pathogenesis is unclear, but may involve the recovery of pathogen-specific responses resulting in the recognition of antigens associated with ongoing or past infection [14]. Bouscarat et al. [15] described ‘immune recovery inflammatory folliculitis’ in seven patients after the commencement of HAART. The lesions involved the face and upper trunk and were usually pruritic. There was no response to topical antibacterial, antifungal or antiparasitic agents. Topical corticosteroid treatment was effective. The cases were ‘acute or subacute', but the time from the commencement of therapy to the presentation of rash was not reported. The cases were associated with a mean CD4 lymphocyte count increase of 124 cells/ml. Details of skin biopsy results were not included, in particular the presence of eosinophils, but Demodex and Pityrosporum were identified in some specimens. The authors hypothesized that the immune response corresponds to the initial increase in specific memory T cells directed against pathogens (e.g. Demodex, Pityrosporum) that were already present. Delfos et al. [16] recently reported two cases of ‘Demodex folliculitis’ as a skin manifestation of immune reconstitution disease. The patients had pruritic skin eruptions on the face and trunk; one had more widespread lesions. The cases occurred 3 weeks and ‘a few days’ after commencing HAART, with increases in the CD4 lymphocyte count of 93–227 and 25–63 cells/ml, respectively. Skin scrapings revealed numerous Demodex mites. Skin biopsy results were not recorded. Topical metronidazole cream was effective in one case, and the addition of oral ivermectin was required in the other. It was suggested that uncontrolled infestation during immunodeficiency was followed by an aggravation of symptoms caused by the reconstitution of immunity and the local influx of immune-associated T cells. However, Demodex mites have been noted with various types of HIV-associated folliculitis with no ascribed causative role [3], and also without any surrounding inflammatory response [4]. We suggest that the cases of eosinophilic folliculitis described here and those noted anecdotally previously [8,11,12], as well as those reported by Bouscarat et al. [15] and Delfos et al. [16] represent a spectrum of one condition. For clarity, and to aid the future study of this phenomenon, we propose the unifying term ‘immune reconstitution folliculitis’ to apply when folliculitis occurs in the setting of immune restoration and needs to be distinguished from clinically important drug reactions or other distinctly identifiable syndromes.

Interventions for rosacea.

Rosacea is a common skin condition affecting the face, characterised by flushing, redness, pimples, pustules and dilated blood vessels. The eyes are often also involved. The cause of rosacea is unclear. It is a chronic disease, which can be controlled in most cases with appropriate treatment. Numerous treatments are in use although it is unclear which are best, and which are most appropriate for the different types of rosacea. To assess and summarise current evidence for the efficacy and safety of treatments for rosacea. We searched the Skin Group Specialised Trials Register (March 2002), Cochrane Central Register of Controlled Trials (CENTRAL, March 2002), MEDLINE (from 1966 to March 2002), EMBASE (from 1980 to March 2002), Biosis (from 1970 to March 2002) and the Science Citation Index (from 1988 to March 2002). Reference lists of trials and key review articles were also searched. Relevant manufacturers and experts were contacted. Randomised controlled trials in people with moderate to severe rosacea were included. Studies judged by the reviewers to have seriously flawed methodology were excluded. Study selection, assessment of methodological quality, data extraction and analysis were carried out by two independent reviewers. The evidence provided by twenty-two included studies was generally weak because of poor methodology and reporting. One of our primary outcome measures, 'quality of life', was not assessed in any of the studies. Only two studies of ocular rosacea could be included. Pooled data from two trials involving 174 participants indicated that topical metronidazole is more effective than placebo (odds ratio 5.96, 95% confidence interval 2.95 to 12.06). Data from a between-patient trial (114 patients) and a within-patient trial (33 patients) of azelaic cream versus placebo were not pooled, but both showed good evidence of efficacy. Data pooled from three studies of oral tetracycline versus placebo involving 152 participants showed that, according to physicians' ratings, tetracycline was effective (odds ratio 6.06, 95% confidence interval 2.96 to 12.42). Some evidence of efficacy of oral metronidazole was provided by one small study. The quality of studies evaluating rosacea treatments was generally poor. There is evidence that topical metronidazole and azelaic acid cream have a therapeutic effect. There is some evidence that oral metronidazole and tetracycline are effective. There is insufficient evidence concerning the effectiveness of other treatments. As many of these treatments are used for rosacea, good RCTs are urgently needed.

The management of rosacea.

Rosacea is a multiphasic disease which is associated with flushing, erythrosis, papulopustular rosacea and phymas; each phase is likely to have its own treatment. Flushing is better prevented rather than treated, and its etiology investigated. Beta-blockers, atenolol in particular, are worthy of prophylactic trials examining their efficacy in treating the flushing associated with rosacea. Currently, clonidine is the only drug available for the treatment of flushing. Treatment for erythrosis includes topical and systemic therapies. Metronidazole 1% cream and azelaic acid 20% cream have been reported to reduce the severity score of erythema. The systemic treatment of erythrosis is based on the association of Helicobacter pylori with rosacea. However, this role is still being debated. Eradication of H. pylori can be achieved using a triple therapy regimen lasting 1 to 2 weeks [omeprazole and a combination of two antibacterials (a choice from clarithromycin, metronidazole or amoxicillin)]. Both the flashlamp-pumped long-pulse dye laser and the potassium-titanyl-phosphate laser may be used in the treatment of facial telangiectases. Both systemic and topical remedies may be used to treat the papulopustules of rosacea. Systemic treatment includes metronidazole, doxycycline, minocycline, clarithromycin and isotretinoin, while topical treatment is based on metronidazole cream and gel. The presence of Demodex folliculorum is important in the inflammatory reaction, whether it is pathogenetic or not. Crotamiton 10% cream or permethrin 5% cream may be useful medications for papulopustular rosacea, although they are rarely successful in eradicating D. folliculorum. Oral or topical ivermectin may also be useful in such cases. Ocular involvement is common in patients with cutaneous rosacea and can be treated with orally administered or topical antibacterials. Once rhinophyma starts to be evident, the only way to correct it is by aggressive dermatosurgical procedures. Decortication and various types of lasers can also be used. Associated conditions, such as seborrheic dermatitis and possible contact sensitizations, deserve attention.

Once-daily topical metronidazole cream formulations in the treatment of the papules and pustules of rosacea

Background: The papules and pustules of rosacea can be effectively treated with topical metronidazole. The optimal concentrations of metronidazole and optimum frequencies of application are uncertain. Traditionally, twice-daily applications have been advised, based on the pharmacokinetic profile of metronidazole. Once-daily applications may be safer and less expensive, and they may enhance patient compliance. Objective: We compared the efficacy and safety of 2 commercially available topical metronidazole formulations (0.75% metronidazole cream formulation and 1.0% metronidazole cream formulation) when both were used in a once-daily regimen. Methods: A multicenter, randomized, investigator-blind, parallel group trial was conducted at 3 separate clinical sites located in 3 US cities. The study enrolled 72 rosacea patients with at least 8 to 50 inflammatory facial lesions (pustules and papules) and moderately severe facial erythema. Patients were randomly assigned to receive either 0.75% metronidazole cream or 1.0% metronidazole cream and instructed to apply the medication once daily for 12 weeks. Patients' lesions were evaluated at baseline and at weeks 3, 6, 9, and 12. Results: There were no significant differences between treatment groups for any of the efficacy parameters evaluated. The overall median percentage change in lesion count at end point for patients in the 0.75% metronidazole cream treatment group was −62% compared with −60% for the 1.0% metronidazole cream treatment group. The overall percentage change in erythema scores at endpoint for patients in the 0.75% metronidazole cream treatment group was −26% compared with −30% for patients in the 1.0% metronidazole cream treatment group. Regarding physician assessment of global severity, 57% of subjects (20/35) in the 0.75% metronidazole cream group compared with 37% of subjects (13/35) in the 1.0% metronidazole cream group were rated as having a clear to mild condition at end point. Both drugs were well tolerated; there was no significant difference in the number of drug-related adverse events between the two agents. Conclusion: This controlled trial demonstrates that both 0.75% metronidazole cream and 1.0% metronidazole cream, when used once daily, provide well-tolerated efficacy for moderate to severe rosacea. (J Am Acad Dermatol 2001;45:723-30.)

Investigation and treatment of demodicid infestation of the youth in Changsha, China (Acari: Demodicidae)

Using cellophane adhesive-tape method, an investigation of demodicid infestation in 2160 students was carried out in Changsha of Huanan province, China. The results shows that the total infestation rate was 19.68%, that there was no significant difference in the demodicid infestation rate between male and female students, the infestation rate of university undergraduates was higher than that of high school students and that most of them were infested with Demodex follicuorum. The detection rate (51. 52%) for three-time examination was higher than the detection rate (28.79%) for one-time examination. The false negative rate of one-time and two-time examination in 34 individuals infested with demodicids was44.12% and 17. 65% respectively. The study suggested that the detection rate could be improved by increasing examination time and that there was correlation between the type of skin lesion and the demodicid infestation. The results of local application and in vitro acaricidal test of 3% Man Nai Jing and 1% metronidazole cream indicated that the acaricidal effectiveness of Man Nai Jing was superior to 1% metronidazole cream and there was no significant difference in the immediate effectiveness on skin lesion for two drugs.

REFLECTIONS ON STRATEGIC-SYSTEMIC THERAPY.

Journal of Marital and Family TherapyVolume 18, Issue 1 p. 3-3 REFLECTIONS ON STRATEGIC-SYSTEMIC THERAPY Don Efron, Don Efron Ontario, Canada Don Efron is Senior Co-Editor and Publisher, Journal of Strategic and Systemic Therapies, P.O. Box 2484, Station B, London, Ontario, CANADA N6A 4G7.Search for more papers by this author Don Efron, Don Efron Ontario, Canada Don Efron is Senior Co-Editor and Publisher, Journal of Strategic and Systemic Therapies, P.O. Box 2484, Station B, London, Ontario, CANADA N6A 4G7.Search for more papers by this author First published: January 1992 https://doi.org/10.1111/j.1752-0606.1992.tb01730.xCitations: 3 AboutRelatedInformationPDFPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessClose modalShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Citation StatementsbetaSmart citations by scite.ai include citation statements extracted from the full text of the citing article. The number of the statements may be higher than the number of citations provided by Wiley Online Library if one paper cites another multiple times or lower if scite has not yet processed some of the citing articles.SupportingSupporting0MentioningMentioning2ContrastingContrasting0Explore this article's citation statements on scite.aipowered by Volume18, Issue1January 1992Pages 3-3 Citation StatementsbetaSmart citations by scite.ai include citation statements extracted from the full text of the citing article. The number of the statements may be higher than the number of citations provided by Wiley Online Library if one paper cites another multiple times or lower if scite has not yet processed some of the citing articles.SupportingSupporting0MentioningMentioning2ContrastingContrasting0Explore this article's citation statements on scite.aipowered by RelatedInformation RecommendedMoxifloxacin five-day therapy versus placebo in acute bacterial rhinosinusitisJames A. Hadley MD, FACS, Ralph Mösges MD, PhD, FAAAAI, Martin Desrosiers MD, FRCSC, Daniel Haverstock MSc, David van Veenhuyzen MB, ChB, MPharmMed, Zeljka Herman-Gnjidic MD, MSc, The LaryngoscopeA double‐blind study of 1% metronidazole cream versus systemic oxytetracycline therapy for rosaceaP.G. NIELSEN, British Journal of DermatologySimulation of modulated reflectionsJeffrey J. Lovelace, Martyn D. Winn, Gloria E. O. Borgstahl, Journal of Applied CrystallographyA complicated quasicrystal approximant ɛ16 predicted by the strong-reflections approachMingrun Li, Junliang Sun, Peter Oleynikov, Sven Hovmöller, Xiaodong Zou, Benjamin Grushko, Acta Crystallographica Section B

Impact of topical metronidazole on the skin and colon microflora in patients with rosacea.

20 patients with rosacea were treated with a 1% metronidazole cream b.i.d. for one month. Sixteen out of twenty patients improved. The skin and intestinal microflora were studied before, during and after treatment. Topical metronidazole did not cause any significant changes in the microflora. No side effects were observed.

Treatment of rosacea with 1% metronidazole cream. A double-blind study

Eighty-one patients with rosacea were treated with either I% metronidazole cream or the cream base as a placebo for two months. The trial was performed double-blind, and the patients were assessed once each month. The variates studied were: (I) overall clinical assessment, (2) lesion counts, (3) degree of erythema, (4) independent photographic evaluation, and (5) patient's opinion. Four patients dropped out of the trial (one treated with metronidazole, three with placebo). In all the variates, I% metronidazole cream proved to be significantly more effective than placebo.