Open Journal Systems

ORIGINAL CONTRIBUTIONS

Received: July 2^nd 2015

Accepted: September 25^th 2015

Treatment of interdigital foot erythrasma with ozonated olive oil

Lourdes Ramírez-Hobak,^a Gabriela Moreno-Coutiño,^b Roberto Arenas-Guzmán,^c Alicia Gorzelewski,^d Ramón Fernández-Martínez^e

^a-c,eSección de Micología, Hospital General “Dr. Manuel Gea González”, Secretaría de Salud

^dEspecialista en Gastroenterología, Práctica privada

Ciudad de México, México

Communication with: Ramón Fernández-Martínez

Telephone: (55) 4000 3058

Email: ramfer2@hotmail.com

Introduction: Erythrasma is caused by Corinebacterium minutissimum producing a porphyrin that with Wood’s light emits a coral-red fluorescence. It is the most common bacterial infection of the feet. Ozonated olive oil decreases the cytoplasm and damages bacterial proteins and lipids. Treatment is with oral erythromycin and there is no consensus regarding the topical therapy of choice. The aim of this paper is to evaluate the therapeutic efficacy of ozonated olive oil in a pilot trial for Erythrasma.

Methods: Experimental, open, observational, descriptive, longitudinal clinical trial at the section of Mycology, of the General Hospital “Dr. Manuel Gea González”. Patients: 10 individuals with interdigital feet Erythrasma. Intervention: ozonated olive oil every 12 hours for 10 days was given.

Results: All patients had disappearance of coral-red fluorescence, erythema, fissures, pruritus, and maceration; two patients persisted with scaling. A cure was obtained in 100 % of patients, similar to oral erythromycin response.

Conclusions: Ozonated olive oil is a good topical treatment option for interdigital Erythrasma avoiding oral medications. Larger studies are required.

Keywords: Erythrasma; Ozone; Therapeutics; Photochemical oxidants

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Erythrasma is a superficial pseudo-mycosis caused by Corynebacterium minutissimum, a diphtheroid, lipophilic, and filamentous bacteria.^1-5 Interdigital erythrasma is the most common bacterial infection of the feet.^3,4 Risk factors are the use of occlusive footwear, moisture, and heat.^1-3 Evidence of interdigital erythrasma in coexistence with other infectious agents is 4.7%,³ including Candida and dermatophytes.^1-3 It is located in the interdigital, axillary, inguinal, and submammary folds.^1-3 In the interdigital spaces of the feet there is erythema, maceration, vesicles, scaling, “cigarette paper” appearance, and fetid odor.^2,3 It is generally asymptomatic but there can be mild itching. Evolution is chronic, with no tendency to remission.³ Diagnosis is made by scanning with Wood’s lamp, which finds a coral red or orange fluorescence due to the porphyrins produced by the bacteria. One may take a smear or surface biopsy stained with periodic acid-Shiff, Gramm, or methenamine silver, finding small coccobacilli in the most superficial portion of the stratum corneum.² The presence of ringworm or thrush should be ruled out by direct examination with potassium hydroxide.^2,5 It is important to emphasize that culture is difficult and not essential for the diagnosis.³

The oral treatment of choice is erythromycin 500 mg every 12 hours for 14 days. Other modes are clarithromycin, azithromycin, and tetracyclines. There is no consensus for the most appropriate topical treatment of interdigital erythrasma of the feet.⁴ Healing is achieved with topical solutions of erythromycin, clindamycin, imidazole derivatives, and sodium fusidate ointments, keratolytic creams or 2% sulfur, and Whitfield’s ointment. Other options are ciclopiroxolamine, mupirocin, and aluminum chloride 20%, or antibacterial soaps.^1-5

Ozone is a gas composed of three oxygen atoms in a cyclic structure. It can react with molecules such as fatty acids, ascorbic acid, albumin, and enzymes that oxidize to donate an electron.⁶ It is obtained by passing pure oxygen through a high voltage gradient, interacting with mono or polyunsaturated fatty acids of vegetable oils such as olive or sunflower, to form stable molecules called primary and secondary ozonides.^6-8 Cutaneously, ozone contacts cell membranes and the lipids that comprise it, resulting in radicals such as hydroxyl and also non-radical cytotoxic species, such as aldehydes,^8-10 which oxidize fatty acids.^8,9 Furthermore, it promotes proinflammatory molecules including Cyclooxygenase-2 inhibitors and heat shock proteins, increases molecules such as keratin 10, which in turn promote the activation of transcription factors, such as nuclear factor kappa-light-chain-enhancer of activated B-cells, through kinase phosphorylation, all of which involves the proliferation, apoptosis, and increase of inflammatory response; it also increases the levels of metalloproteinases, enhances wound healing,⁸ raises circulation and donates oxygen to the ischemic tissue without irritation, corrects chronic oxidative stress stimulating the antioxidant system, and promotes activation of the immune and neuroendocrine systems.⁹ In conclusion, oxidative stress is promoted for the guest to generate an adaptive response to it. It can be applied safely to the skin for its protective activity of the stratum corneum and its lipids.^8,9 It is recognized that ozone has antibacterial, antiviral, and antifungal properties.^8,9

Lezcano and Curtiellas et al. demonstrated the bactericidal activity of ozonated sunflower oil in vitro against Staphylococcus aureus, Streptococcus, Pseudomonas, and Escherichia in type strains from the Biological Resource Center with minimum inhibitory concentrations of 0.3 to 4.8 mg/mL with slight variations in strains obtained from clinical isolates and depending on the exposure time to ozonated oil.^11,12

The antimicrobial activity of ozonated vegetable oil is attributed to the action of peroxy compounds present therein on the biomolecules most sensitive to oxidative attack, such as unsaturated lipids and proteins with sulfhydryl groups. Curtiellas et al. studied cell damage in bacteria in vitro by transmission electron microscopy to determine structural changes, the release of K+ ions to assess cell permeability, and measuring total sulfhydryl groups to evaluate the protein and lipid damage, finding no microscopic structural change in the cell membrane, but rather decreased cytoplasm and damage to proteins and lipids.^12,13

Menendez et al. evaluated the activity of ozonated sunflower oil versus mupirocin in patients with impetigo, finding cure rates of 92.9 and 100%, respectively.¹⁴

Given the above background, it was considered that ozonated olive oil can be a good alternative for the topical treatment of skin infections like erythrasma, avoiding oral medication. No clinical studies have evaluated its effectiveness in treating erythrasma.

Objective

To evaluate the therapeutic efficacy of ozonated olive oil in erythrasma in a pilot test.

Methods

Design

An experimental, open, observational, descriptive, and longitudinal clinical study. The study was approved by ethics and research committees and all patients gave written consent to participate in the study.

The study was conducted in the Mycology section of the División de Dermatología, Hospital General "Dr. Manuel Gea González".

Patients

10 patients were included with clinical diagnosis of erythrasma without comorbidities. Demographics such as gender, age, and occupation were recorded. Their type of footwear used was determined and it was made sure that they had not used topical or oral antibiotic or antifungal treatments or talcum powder in the 6 months prior to the study. The clinical data were evaluated: erythema, scaling, cracking, itching, and maceration. All underwent direct examination with potassium hydroxide 10% to make sure they did not have interdigital tinea, and examination with Wood's lamp in a dark room.

Interventions

The 10 patients were prescribed ozonated olive oil (Ozylab) in the interdigital spaces every 12 hours for 10 days. They were evaluated forty-eight hours after stopping treatment to avoid the presence of ozonated olive oil causing confusion upon examination with Wood’s lamp.

Results

Nine patients were female with one male, with an age range of 15-66 years. Three wore sneakers, six closed-toed shoes, and one plastic shoes. Clinical data before and after treatment are reported in Table I and Figures 1 and 2. 100% of the patients had clinical cure in 10 days.

Discussion

Few studies describe the effectiveness of oral and topical agents in treating erythrasma.^4,5 Oral erythromycin is very effective for the treatment of erythrasma with cure rates (clinical and bacteriological) of approximately 100%. Sevilla and Somerville conducted a study showing that oral erythromycin was as effective as tetracyclines in interdigital lesions with 56% compared to 50%, respectively.⁴

Whitfield's ointment is more effective than systemic erythromycin with 100% versus 56.5%, respectively, and it is also more effective than tetracyclines, with 98% versus 50%.⁴ In a double-blind study comparing sodium fusidate against Whitfield’s ointment, Somerville et al. showed comparable cure rates for this disease in feet with 89% versus 90% with the application of the drugs for 14 days. Sodium fusidate ointment was less effective in removing scaling. On the other hand, antibacterial soap is more effective than non-antibacterial in resolving lesions from erythrasma.⁴

Other studies report that the response rate of oral erythromycin in the treatment of erythrasma is 77% compared to fusidic acid 2%, whose response rate was 99%, with less recurrence than the former.⁵

The use of oral clarithromycin in single dose has been proposed as a treatment for erythrasma and it appears to be an economic, effective, and safe option with good tolerance and adherence by the patient.⁵

Avci et al. report that the efficiency of fusidic acid is higher than any alternative. They also found that clarithromycin is more effective than erythromycin during the first 48 hours of treatment but no difference to 7 and 14.⁵

In this study it is striking that the clinical cure rate was 100% with 10 days of treatment with ozonated olive oil with symptoms disappearing except for scaling, which persisted in two patients.

Conclusions

The advantages of treating erythrasma with ozonated olive oil is that the effectiveness was 100% and without adverse effects, avoiding systemic treatment such as erythromycin, whose cure rate is 77%, and wasting time with preparing custom formulations. With regard to fusidic acid, ozonated oil is cheaper and currently is readily available.

Although the sample size was small, the therapeutic efficacy of ozonated olive oil in interdigital erythrasma of the feet is clear. A study is planned with a statistically representative sample.

References

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