Use Of Topical Steroids Research Articles

Obsession to fairness and topical steroid induced acne: A situation analysis of patients presenting in dermatology clinic at a private hospital in Karachi.

To determine the frequency of acne and other relevant side effects as well as the pattern of topical steroid and fairness cream use among patients presenting with steroid and fairness cream use at dermatology OPD in a tertiary care private hospital in Karachi. A cross-sectional survey was conducted from April, 2020 to December, 2020 in a private tertiary care hospital in Karachi. In total, 226 patients with a positive history of topical steroids and/or fairness creams use in the past six months were included in the study. Information was collected about sociodemographic characteristics; topical corticosteroid uses while clinical examination of facial skin was performed by a dermatologist. Data were analyzed using SPSS version-19. The median age of study participants was 26 years with an interquartile range of 10 years. This frequency of corticosteroid induced acne was highest i.e., 83.6% (n=189) followed facial erythema and telangiectasia i.e., 50.9% (n=115) 47.8% (n=108) respectively. The estimated median duration of using topical steroids or fairness creams or both was six months with an IQR of four months. The study found statistically significant differences in the reasons of using topical corticosteroids or fairness creams on the face on the basis of differences in the level of education and marital status. In Karachi, both, men and women are equally obsessed with fair skin tone and use topical steroids and fairness cream. The use of corticosteroid or fairness cream-induced facial acne is alarmingly high among patients presenting in a dermatology clinic in Karachi.

Closure of a Chronic Traumatic Macular Hole Following Phacoemulsification Surgery.

To report a case of chronic traumatic macular hole closure following an uncomplicated phacoemulsification surgery. Retrospective chart review with optical coherence tomography imaging. 42-year-old woman with a 20-year history of a traumatic macular hole and cataract in the right eye underwent an uncomplicated phacoemulsification surgery. Following surgery, the patient was prescribed prednisolone acetate 1% four times per day, which was tapered off by postoperative month 1. By postoperative month 1, the full-thickness macular hole had closed. This unique case illustrates the closure of a full-thickness macular hole following cataract surgery. We hypothesize that closure of the macular hole was aided by the use of topical steroids in the postoperative period, allowing for resolution of the cystic intraretinal fluid and hole closure.

Compatibility of Topical Products to Manage Skin Irritation Associated with TTFields.

Tumor Treating Fields (TTFields) are electric fields that disrupt cellular processes critical for cancer cell viability and tumor progression. TTFields therapy is approved for the treatment of recurrent glioblastoma (GBM), newly diagnosed GBM, and pleural mesothelioma, and is currently under clinical investigations for the treatment of other types of cancers. TTFields therapy is delivered continuously and non-invasively, using a portable signal generator connected to 4 arrays attached to the skin. Treatment of at least 18 hours per day is recommended for increasing effectiveness. The main treatment-related adverse effect reported in clinical trials and post-marketing surveillance studies has been low-grade skin irritation under the arrays, which may be treated in most cases with the use of topical steroids or intermittent treatment interruptions. However, for maintaining treatment effectiveness, skin care products suitable for use under the TTFields arrays are those that do not affect field currents. The goal of this study was to investigate strategies to alleviate skin irritation without compromising treatment effectiveness. TTFields (200 kHz) were applied to rats (Sprague Dawley, 10-20 weeks of age, body weight over 250 gr) using ceramic disks and hydrogels identical to those used with human arrays. The rat torso was depilated, and TTFields were applied to the rat torso before and after applying various skin care products to the surface beneath the arrays. After reaching a steady state, average currents were extracted from the device's log files. Percent change in current was calculated from the measurements with and without the product. Tested products could be divided into groups according to their medical use: antibiotics, antiseptics, cleansers/adhesive removers, skin barriers, moisturizers, topical corticosteroids, and antiperspirants. The products could also be categorized by their type: creams, gels, soaps, sprays, ointments, wipes/pads, foams, and lotions. Skin care products that significantly reduced currents were mainly ointments. Typical ingredients of ointments are mineral oil and petrolatum, which are expected to create a hydrophobic layer, thereby reducing ionic conduction and hence field currents. These ingredients also hinder adherence of the acrylic-based tape to the skin thus compromising mechanical fixation of the arrays, leading to poor connectivity and hence reduced currents. Identification of products for treating skin irritation that are compatible with TTFields therapy is important for improving patient's quality of life and increasing device usage. Skin care products containing petrolatum should not be applied under the arrays to avoid compromising treatment effectiveness.

Characterization of Objective Skin Color Changes during and after Breast and Chest Wall Radiotherapy and Correlation with Radiation-Induced Skin Toxicity in Breast Cancer Patients, Including Patients with Skin of Color

Radiation dermatitis (RD) is common among women undergoing breast and chest wall radiotherapy (RT); however, existing scales to assess the severity of RD are subjective and do not account for variability in skin of color (SOC). For instance, the Common Terminology Criteria for Adverse Events (CTCAE) criteria do not include hyperpigmentation in the grading scale. There is data indicating worse RD in African American and Hispanic patients; however, the rate and severity in SOC remains unknown given the lack of data using objective measures of RD. Spectrophotometry is one method to quantify the appearance of color by measuring spectral characteristics without the bias associated with subjective clinical scoring. We present a phase I prospective non-therapeutic clinical trial to objectively define SOC at baseline and evaluate spectrophotometric skin changes during and after breast or chest wall RT in parallel with physician-graded RD using CTCAE criteria. We hypothesize that there will be greater discrepancy between physician graded RD and objective measures of RD in patients with SOC in whom hyperpigmentation will be undercaptured by physician-grading. This is the first study intending to correlate SOC with objective changes after RT as a reliable indicator of RD. We offer a novel system for evaluating RD that is applicable to SOC. A total of 60 patients with localized breast cancer (stage 0-III) undergoing conventional whole breast or chest wall RT (50Gy/ 25 fx), hypofractionated whole breast RT (40.5Gy/15 fx) or ultrahypofractionated partial breast RT (6Gy x5), with or without regional nodal RT were enrolled. 3 skin color readouts using the Commission International de l'Eclairage 3D color system (l*, a*, b*) were measured within the radiation field using a spectrophotometer at baseline, once weekly during RT, 10 days post RT, 4 weeks and 12 months post RT. The spectrophotometer is a non-invasive, hand-held device that is used in the clinic room with no additional equipment or setup requirements. Data is automatically exported to a spreadsheet organized by timepoint and patient. The l* axis is a gray scale (0 = black, 100 = white) correlating with skin pigmentation and the a* axis describes red and green values correlating with erythema. The primary objective is to evaluate the changes from baseline in skin color readouts in the quadrant of tumor location during and after RT based on fractionation. The secondary objective is to evaluate changes within and across groups defined by baseline skin color. Exploratory objectives include evaluating the association of baseline color readouts and changes after RT with acute and late grade > 2 clinician-rated skin and subcutaneous tissue effects according to the CTCAE, v5.0, physician graded cosmesis and clinical interventions to treat RD, such as use of topical steroids and oral analgesics. As of January 2023, we have enrolled 100% of the planned patients. To be determined. To be determined. Clinical Study Identifier: S22-00192.

Infectious and Noninfectious Corneal Ulcers in Ocular Graft-Versus-Host Disease: Epidemiology, Clinical Characteristics, and Outcomes

To evaluate the incidence, clinical characteristics, microbiological profile, and therapeutic outcomes of corneal ulcers in individuals with chronic ocular graft-vs-host disease (coGVHD). Retrospective clinical cohort study. Review of individuals diagnosed with coGVHD following hematopoietic stem cell transplantation (HSCT) who were seen at the Bascom Palmer Eye Institute between May 2010 and November 2021. Baseline demographics, clinical characteristics, microbiological profile, risk factors for corneal ulceration, and treatment outcomes were collected. Etiology was deemed infectious in individuals with a positive culture or appropriate clinical scenario (presence of stromal infiltrate or hypopyon); otherwise, ulcers were presumed to be noninfectious. Treatment success was defined as reepithelialization with infiltrate resolution, and treatment failure as progression to corneal perforation or keratoplasty. Kaplan-Meier survival analysis estimated the incidence of ulceration. Cox regression analyses examined demographic and risk factors. Infectious and noninfectious ulcer groups were compared using 2-way independent t tests, 1-way analysis of variances, and χ2 tests, as appropriate. 173 individuals were included (53.7±14.4 years old; 59.0% male). Thirty-three individuals developed an ulcer 74.5±54.3 months after HSCT, with estimated 5- and 10-year incidences of 14% and 30%, respectively. Twenty-two (66.6%) ulcers were deemed infectious (15 microbiologically confirmed, 7 clinically) and 11 (33.3%) were deemed noninfectious. Risk factors for corneal ulceration included Black race (hazards ratio [HR] 2.89, 95% CI 1.30-6.42, P < .01), previous ocular surgery (HR 9.16, 95% CI 3.86-21.72, P < .01), eyelid margin abnormalities (HR 3.44, 95% CI 1.69-6.99, P < .01), and topical steroid use (HR 2.74, 95% CI 1.33-5.62, P < .01). Conversely, contact lens use reduced the risk of corneal ulceration (HR 0.29, 95% CI 0.13-0.66, P < .01). Infectious ulcers had a significantly higher frequency of treatment failure than noninfectious ulcers (57.1% vs 20.0%, P=.04). Corneal ulceration is a potential complication of coGVHD, with several clinical features identified as risk factors. Infectious ulcers had worse outcomes than noninfectious ulcers.

Microbiological Characteristics and Risk Factors Involved in Progression from Fungal Keratitis with Hypopyon to Keratitis-Related Endophthalmitis.

To investigate the differences in microbiological characteristics, risk factors, drug resistance, and visual outcomes in three infections: fungal keratitis with hypopyon (FKH), keratitis-related fungal endophthalmitis (FKE), and fungal endophthalmitis without keratitis (FE). An analytical cross-sectional study. In total, 14.57% of eyes with FKH progressed to endophthalmitis. Hypopyon, pre-existence of lens problems, topical steroid use and sever keratitis were significantly associated with the development of FKE. The risk factors of the FKH and FE group were mainly plant trauma and open globe trauma, respectively. Keratitis-related endophthalmitis (FKE) showed a significantly higher resistance than the other two groups. The FKH group had the best final visual acuity, while the FKE group had the worst. Hypopyon height, pre-existing lens problems, topical steroid use and sever keratitis are risk factors for progression to endophthalmitis in eyes with fungal keratitis, and its progression is not affected by a single fungus. The antifungal drugs resistance in patients with endophthalmitis related to keratitis was significantly higher than that associated with other reasons. Timely diagnosis and risk factor assessment are essential for ensuring early treatment of FKE.

Clinical comparative analysis of culture-proven bacterial keratitis according to prior topical steroid use: a retrospective study in a tertiary referral center of South Korea

This study analyzed the clinical characteristics of patients exposed to topical steroids before bacterial keratitis diagnosis (the prior topical steroid use, PS group), and compared these with those of the non-exposed group (the no prior topical steroid use, NPS group). We retrospectively analyzed 194 patients (PS, 34; NPS, 160) with culture-proven bacterial keratitis between 2007 and 2016. The microbiological profiles, epidemiology, predisposing factors, clinical characteristics, and treatment outcomes of PS and NPS were compared, and the risk factors for surgical intervention were evaluated. Pseudomonas spp. and Staphylococcus spp. were the most common isolates in PS and NPS, respectively, and no significant difference in the strain distribution between the two groups were observed. Significant differences were observed between PS and NPS for previous ocular surface disease (41.2%: 23.8%), initial BCVA < 0.1 (70.6%: 49.4%), epithelial defect size ≥ 5 mm2 (64.7%: 41.2%), epithelial healing time > 14 days (55.9%: 37.3%), and surgical intervention (23.5%: 8.8%). Prior topical steroid use, strong steroid use, and long-term steroid use groups were included in significant risk factors for surgical intervention. Previous exposure to topical steroids before the diagnosis of bacterial keratitis was associated with a worse initial clinical presentation and treatment outcomes. Additional multicenter studies should be conducted in the future.

Clinicomycological Profile and Risk Factors for Dermatophytosis at a Teaching Tertiary Care Centre in North India: A Cross-sectional Study.

Dermatophytosis has gained significant importance in recent years owing to increased incidence, more atypical lesions, changing mycological profile and growing antifungal resistance. Therefore, this study was planned to know the clinicomycological profile of dermatophytic infections in patients attending our tertiary care centre. A total of 700 patients with superficial fungal infections belonging to all age groups and both sexes were taken up for this cross-sectional study. Sociodemographic and clinical details were noted on a prestructured proforma. Superficial lesions were clinically examined and the sample was collected by appropriate collection methods. Direct microscopy by potassium hydroxide wet mount was done to see hyphae. For culture Sabouraud's dextrose agar (SDA) with chloramphenicol and cyclohexamide was used. Dermatophytic infections were detected in 75.8% (531/700) patients. Young people belonging to age group of 21-30 years were commonly affected. Tinea corporis was the commonest clinical picture seen in 20% of the cases. Oral antifungals were taken by 33.1% and topical creams were used by 74.2% of the patients. Direct microscopy was positive in 91.3% and culture was positive for dermatophytes in 61% of the study subjects. T. mentagrophytes was the commonest dermatophyte isolated. Irrational use of topical steroids needs to be controlled. KOH microscopy can be useful as a point of care test for rapid screening of dermatophytic infections. Culture is necessary to differentiate various dermatophytes and to guide the antifungal treatment.

41385 Investigating efficacy of PDE-4 inhibitors in reducing topical steroid use for management of pediatric atopic dermatitis: A double-blind randomized control study

41385 Investigating efficacy of PDE-4 inhibitors in reducing topical steroid use for management of pediatric atopic dermatitis: A double-blind randomized control study

A 7-year review of clinical characteristics, predisposing factors and outcomes of post-keratoplasty infectious keratitis: the Nottingham infectious keratitis study.

Post-keratoplasty infectious keratitis (PKIK) is a unique sight-threatening clinical entity which often poses significant therapeutic challenges. This study aimed to examine the clinical presentation, risk factors, management, and clinical outcomes of PKIK. This was a retrospective study of all patients who presented to the Queen's Medical Centre, Nottingham, with PKIK between September 2015 and August 2022 (a 7-year period). Relevant data on types of keratoplasty, clinical presentations, causative microorganisms, management, and outcome were analyzed. Forty-nine PKIK cases, including four cases of interface infectious keratitis, were identified during the study period. The most common graft indications for PKP, DALK and EK were failed grafts (9, 37.5%), keratoconus (6, 54.5%) and Fuchs endothelial corneal dystrophy (FECD; 8, 57.1%), respectively. Staphylococcus spp. were the most commonly identified organisms (15, 50.0%). Bullous keratopathy (18, 36.7%), ocular surface disease (18, 36.7%), and broken/loose sutures (15, 30.6%) were the most common risk factors. Concurrent use of topical steroids was identified in 25 (51.0%) cases. Of 31 functioning grafts at presentation, 12 (38.7%) grafts failed at final follow-up with 15 (48.4%) patients retaining a CDVA of ≥1.0 logMAR. The overall estimated 5-year survival rate post-PKIK was 55.9% (95% CI, 35.9%-75.9%), with DALK having the highest survival rate [63.6% (95% CI, 28.9%-98.3%)], followed by EK [57.1% (95% CI, 20.4%-93.8%)] and PKP [52.7% (95% CI, 25.1%-80.3%)], though no statistical difference was observed (p=0.48). PKIK represents an important cause of IK and graft failure. Bullous keratopathy, OSD and suture-related complications are the commonest risk factors, highlighting the potential benefit of prophylactic topical antibiotics (for unhealthy ocular surface) and early suture removal (where possible) in reducing the risk of PKIK. Graft survival may be higher in lamellar keratoplasty following PKIK but larger studies are required to elucidate this observation.

P18 Epidermolysis bullosa acquisita in children: report of three cases

Abstract Epidermolysis bullosa acquisita (EBA) is an acquired, subepidermal blistering skin disease characterized by autoantibodies against type VII collagen, which links the epidermis to the dermis at the dermo-epidermal junction. Clinically, patients have skin fragility and blisters over trauma-prone sites, scarring, milia and onychodystrophy. The diagnosis can be challenging as it shares clinical and histopathological features with other immunobullous diseases. Although exceptionally rare in children, we report three paediatric patients with EBA and variable disease severity. The main clinical features were blisters (n = 3), milia (n = 3), scarring (n = 2), oral erosions (n = 2) and onychodystrophy (n = 1). Histological findings were nonspecific, showing a subepidermal blister with various inflammatory infiltrates. On direct immunofluorescence a bright deposit of IgG was seen, and the antibodies adhered to the dermal side of the salt-split in two cases. ELISA analysis confirmed circulating autoantibodies against type VII collagen in one patient. All received a course of oral corticosteroids alongside steroid-sparing agents such as dapsone, azathioprine and rituximab depending on clinical response and shared favourable prognosis. Early use of topical steroids can help but high-dose oral corticosteroids are often required as well as steroid-sparing agents such as dapsone, methotrexate, azathioprine, ciclosporin, mycophenolate mofetil, cyclophosphamide and rituximab. In our experience, although the treatment approaches have been different, all the patients had favourable outcomes.

INDIVIDUAL ARTICLE: Fixed Combination Calcipotriene/Betamethasone (Cal/BDP) Cream: Evaluating the Role of Polyaphron Dispersion (PAD) Technology in Psoriasis Treatment.

Most patients with plaque psoriasis exhibit mild-to-moderate disease and topical therapies remain the mainstay treatment option for these patients. The use of topical steroids in combination with vitamin D analogs can produce synergistic effects and minimize adverse effects. However, due to the incompatible pH ranges of topical steroids and vitamin D analogs, combination formulations can be difficult to manufacture. Until recently, only anhydrous formulations of these 2 agents were developed as foam, gel/suspension, and ointment. However, anhydrous vehicles can often result in greasy or oily skin, thus limiting treatment adherence. Recently, Polyaphron Dispersion (PAD) technology presents a new, more cosmetically appealing vehicle that allows for both topical steroids and vitamin D analogs to coexist in an aqueous environment, such as a cream formulation. The calcipotriene/betamethasone dipropionate (CAL/BDP) cream enhances drug delivery by reducing the greasy and oily side effects of anhydrous formulations. Phase 3 clinical trials have demonstrated CAL/BDP cream&rsquo;s superior efficacy in treating psoriasis over gel/suspension, and the clinical trials have also shown significantly improved patient satisfaction with the cream formulation.&nbsp; &nbsp.

Clinico-Mycological Profile of Recurrent Dermatophytosis with Drug Sensitivity in a Tertiary Care Center in Southern Odisha

Background: Recurrent dermatophytosis is a pressing problem worldwide due to inadequate treatment, drug resistance, and indiscriminate use of topical steroids. This scenario increases the need for the study of risk factors and antifungal susceptibility testing. There is a paucity of information on this subject. Objective: We aimed to find the clinico-mycological pattern of recurrent dermatophytic infections, the factors responsible for recurrence and determine the sensitivity pattern of isolates against four antifungals (fluconazole, itraconazole, terbinafine, and amphotericin B). Materials and Methods: Patients with recurrent dermatophytosis attending the outpatient Department of Our Tertiary Care Institute were enrolled in this study. A detailed history was taken; clinical examination was done; samples were collected for mycological examinations, and in-vitro antifungal sensitivity testing was done by broth microdilution method as per Clinical and Laboratory Standard Institute M38-A guidelines. Results: One hundred and twenty-eight patients were included in the study with a male:female ratio of 1.38:1. The most commonly affected age group was 31–40 years. Tinea corporis with tinea cruris was the most common type of clinical presentation. Potassium hydroxide mount was positive in 53 samples and culture was positive in 59 samples. Trichophyton rubrum was the predominant species isolated, followed by Trichophyton mentagrophytes. On in-vitro antifungal susceptibility testing, itraconazole and amphotericin B had the lowest minimum inhibitory concentrations (MIC), followed by terbinafine. Fluconazole had the highest MIC among the drugs tested. Conclusion: Topical corticosteroid abuse, lack of personal hygiene, and habit of sharing clothes were seen in many patients with recalcitrant dermatophytosis. T. rubrum was the most common isolated species. Antifungal susceptibility testing revealed itraconazole and amphotericin B to have the lowest MIC value and fluconazole to have the highest MIC value.

Severe Irritant Contact Dermatitis of the Face: New Natural Approaches in the Topical Treatment

Contact dermatitis is a common skin condition characterized by inflammation, be it acute or chronic, occurring as a result of interaction with irritant substances. It can be categorized as either irritant contact dermatitis (ICD) or allergic contact dermatitis (ACD). Contact dermatitis is currently one of the most common occupational diseases, with capability of involving any given part of skin and a predilection for the face and extremities. Irritant-contact dermatitis represents the majority of cases (around 80%), while the remaining instances are caused by interaction with allergens. Nonetheless, correctly diagnosing and treating forms of ICD remains difficult, with treatments for contact dermatitis currently based on the identification and avoidance of the underlying cause, along with the use of topical steroids and emollients, with creams frequently recommended in preventative skin care programs for the workplace.

PS03 Dermatologist perspectives on topical steroid withdrawal: distrust, disinformation and distance?

Abstract Topical steroid withdrawal (TSW) has become a polarizing phenomenon. The TSW has been described as ‘intense erythema and burning…more prolonged than can be explained by the rebound vasodilation that occurs after discontinuing topical steroids’ (Cotter C, Burton T, Proctor A et al. Topical steroid withdrawal syndrome: time to bridge the gap. Br J Dermatol 2022; 187:780–1). However, TSW acceptance and consensus around diagnosis have proven elusive among dermatologists. This contrasts with a growing patient movement online, with &amp;gt; 572 million views of #topicalsteroidwithdrawal on TikTok. Disparities between patient and clinician acceptance have care implications, relating to psychological wellbeing and engagement with services (Scott S, Deary I, Pelosi AJ. General practitioners’ attitudes to patients with a self diagnosis of myalgic encephalomyelitis. BMJ 1995; 310:508). Self-reported diagnosis of previous emergent, ‘unexplained’ conditions like myalgic encephalomyelitis led to negative clinician attitudes regarding patient concordance, potentially leading to worse outcomes and psychological burden. This study aimed to clarify dermatologist perspectives regarding TSW and assess attitudes toward self-diagnosis. A two-part online questionnaire was developed and disseminated to UK-based dermatology consultants, registrars and fellows via social media and email. Section one presented a TSW clinical scenario and randomized respondents into two groups, one mentioning self-diagnosis of TSW and an otherwise identical control without self-diagnosis. Questions focused on attitudes regarding patient predicted behaviours. Section two asked perspectives on TSW as an entity and management experiences. Comparative data were analysed via SPSS (IBM, Armonk, NY, USA) using statistical tests. In total, 103 responses were received, including those from 51 consultants and 38 registrars. Thirty-four per cent of respondents considered TSW to be a distinct clinical entity, 17.5% did not and 48.5% were unsure. The cohort had seen at least 599 patients presenting with a self-diagnosis of TSW but made the diagnosis itself 157 times. Eighty-two per cent linked the diagnosis to social media and 96.1% most associated TSW with eczema. Eighteen per cent felt their patients with TSW were receiving adequate care. There were statistically significant differences whereby respondents felt patients self-diagnosing with TSW were less likely to comply with treatment (P = 0.003), were more likely to take up one’s time (P = 0.001), would pose difficult management problems (P ≤ 0.001) and would be less desirable on clinic lists compared with controls not mentioning TSW (P ≤ 0.001). Qualitative themes included inappropriate topical steroid use, patient mistrust and desire for further research. Many dermatologists encounter patients presenting with TSW self-diagnoses, but uncertainty regarding its validity is common. Clinicians see this phenomenon as strongly linked to eczema and as being driven by social media. Patients self-diagnosing with TSW were more likely to be viewed negatively in terms of treatment concordance and difficulty with management. A minority of dermatologists believe their patients with TSW are receiving adequate care. Further research is essential to achieve consensus and support patients.

PA22 Topical tacrolimus management of chronic recurrent skin reaction to mauve stinger jellyfish envenomation

Abstract Chronic skin eruptions may follow the acute reaction to envenomation by some jellyfish, the incidence and management of which are not well described. We describe management with topical tacrolimus of a chronic eruption following envenomation by Pelagia noctiluca (‘mauve stinger’), one of the most common stinging jellyfish in the Mediterranean Sea. An 8-year-old girl was stung on the arm by a P. noctiluca in Menorca, Spain. First-aid measures with vinegar and topical antihistamine were administered, and the discomfort settled within 24 h. Five days later, the sting site became increasingly painful and itchy, with superficial ulceration and arm swelling. A second sting site on the lower leg reacted in a similar manner. She was systemically well. She was treated with oral co-amoxiclav, fusidic acid and betamethasone valerate 0.1% cream, and nonadhesive dressings. She initially responded well, but was required to continue the use of potent topical steroid after 3 weeks, as the symptoms recurred within 48 h of halted application. The use of topical tacrolimus cream 0.03% achieved symptom control when used in a slowly weaning regime over 3 months, with a brief flare of skin symptoms around the time of contracting COVID-19. She has now been asymptomatic for 12 months, and the sting site is a maturing scar. Envenomation reactions to jellyfish of the phylum Cnidaria (including P. noctiluca) are the result of varying pathophysiological mechanisms. The tentacles and bell of P. noctiluca carry toxin-releasing epithelial organelles called nematocysts. When triggered, the stinging apparatus fires, injecting thousands of mineralized spine-covered tubules and toxins such as porins [Yanagihara AA, Wilcox C, Smith J, Surrett GW. Cubozoan envenomations: clinical features, pathophysiology and management. In: The Cnidaria, Past, Present and Future (Goffredo S, Dubinsky Z, eds). Cham: Springer, 2016; 637–52]. Acute tissue damage and inflammation are caused by physical trauma and venom effects. Vinegar used at the time of a sting may permanently prevent discharge from unfired and noninjected nematocysts. Hot-water immersion for 30 min inactivates venom, and topical steroids reduce inflammation. The delayed and prolonged skin response (presenting after the primary reaction to envenomation), as in our case, is likely to be an immunological response to the retained, embedded nematocyst structures and may include granulomatous reactions, and eventually scarring. Optimal acute first-aid measures (as above) are thought to reduce incidence of late skin sequelae. This report highlights the successful use of topical tacrolimus immunomodulation for an established delayed reaction.

Amniotic Membrane Transplantation in the Management of Corneal Ulceration Following Infectious Keratitis

ABSTRACT Purpose To report on the outcomes of amniotic membrane transplantation (AMT) for corneal ulceration following infectious keratitis. Method In this retrospective cohort study of 654 patients with culture-proven infectious keratitis from 8 hospitals in Galicia (Spain), a total of 43 eyes of 43 patients (6.6%) underwent AMT for postinfectious corneal ulceration. The indications for AMT were sterile persistent epithelial defects, severe corneal thinning or perforation. Results AMT was successful in 62.8% of cases, with 37.2% requiring an additional surgery. Median time to healing was 40.0 days (IQR 24.2–101.7 days) and final BCVA was lower than baseline (p = 0.001). Ulcers were large (>3 mm) in 55.8% of cases. Previous herpetic keratitis and topical steroid use were more common in patients who received AMT (p < 0.001). 49 microorganisms (43 bacteria and 6 fungi) were isolated. Conclusions AMT is a therapeutic option for complications following infectious keratitis, which present with a sterile persistent epithelial defect, significant corneal thinning or perforation.

Clinical Features, Risk Factors, and Management of Candida Keratitis

ABSTRACT Background/Aims To determine the clinical features, predisposing factors, and management of infectious keratitis caused by Candida spp. Methods Retrospective chart review. Results The medical records of 52 patients (54 eyes) with Candida keratitis were available for statistical analysis. Thinning of the corneal stroma was identified in 34 eyes (63.0%), and corneal perforation occurred in 16 eyes (29.6%). Corneal thinning and perforation were more common in Candida albicans compared with non-albicans (P-val < .001, P = .09, respectively). The most common predisposing factors for Candida keratitis were topical steroid use (21 patients, 40.4%), previous corneal transplantation (17 patients, 32.7%), and preexisting ocular surface disease (15 patients, 28.8%). Fourteen eyes (25.9%) required cyanoacrylate glue application and 10 eyes (18.5%) underwent therapeutic penetrating keratoplasty (TPK). Conclusion Local immunosuppression and ocular surface disease play an important role in Candida keratitis. C. albicans appears to be more invasive compared with non-albicans spp.

Long-Term Hearing Outcomes After Hybrid Cochlear Implantation.

To examine long-term (>5 yr) low-frequency hearing preservation after hybrid cochlear implantation. Retrospective cross-sectional study. Tertiary care center outpatient clinic. All patients older than 21 years implanted with a Cochlear Hybrid L24 device from 2014 to 2021. Changes in low-frequency pure-tone average (LFPTA) were calculated at each of several time points relative to the date of implantation. The proportion of patients with preserved LFPTA at last follow-up and Kaplan-Meier estimates for loss of residual hearing were calculated in addition to hazard ratios for hearing loss according to patient- and surgery-specific factors. Thirty ears in 29 patients underwent hybrid cochlear implantation and were eligible for inclusion (mean age, 59 yr; 65% female). Mean preoperative LFPTA was 31.7 dB. Mean LFPTA across all implanted ears at first follow-up was 45.1 dB; no patient had experienced loss of residual hearing at first follow-up. Six patients had loss of residual hearing during the follow-up period, with Kaplan-Meier probability estimates of preserved hearing of 100% at 1 month, 90% at 12 months, 87% at 24 months, and 80% at 48 months. There was no association between loss of residual hearing and patient age, preoperative LFPTA, surgeon, or use of topical steroids intraoperatively (hazard ratios, 1.05 [0.96-1.15], 0.97 [0.88-1.05], 1.39 [0.20-9.46], 0.93 [0.09-9.74], respectively). Long-term (>5 yr) outcomes after hybrid cochlear implantation demonstrate good preservation of low-frequency hearing, with only modest decline in the long-term postimplantation, and a low proportion of loss of residual low-frequency hearing.

Comparison of Effectiveness of Hiora SG Gel With Triamcinolone Acetonide Gel in Recurrent Aphthous Stomatitis.

Background The oral condition known as recurrent aphthous ulceration (RAU) or recurrent aphthous stomatitis (RAS) is very prevalent. Its etiopathogenesis is unknown; hence, symptomatic therapy is all that can be offered if it manifests clinically. Lesion care aims to minimize discomfort and the frequency of relapses by bringing active illness under local control in the affected area. The current treatment options that may have negative side effects include the use of topical and systemic steroids, antibiotics, cauterization, and laser therapy. Objectives and Importance This study aimed to compare the efficiency of HiOra SG gel with triamcinolone acetonide gel in the management of RAS. Materials and Methods Fifty individuals with RAS were recruited for the trial and randomly assigned to either group I (HiOra SG gel) or group II (0.1% triamcinolone acetonide ointment; Oraways). After each meal for a total of 10 days, those with mouth ulcers were instructed to topically administer the drugs. The clinical data were analyzed by comparing the ulcer severity scores from the first, fifth, and 10th days. Results There was a statistically significant (p = 0.001) reduction in reported pain, pain duration, and overall ulcer severity across all groups. After therapy, however, neither the HiOra gel group nor the triamcinolone group showed any discernible improvement over the other. Conclusion The present study's findings corroborate the efficacy of HiOra SG gel in the treatment of RAS when compared to triamcinolone acetonide gel (0.1%). In this trial, no patients had any negative reactions to HiOra SG gel. In the future, further studies are needed with larger samples to prove its benefits.