Successful treatment of severe and recurrent hand eczema with infection in human immunodeficiency virus patients: A case report

Abstract

Hand eczema is a common allergic disease characterized by a chronic relapsing course with a 15% lifetime prevalence. Human immunodeficiency virus-infected individuals have a higher risk of Staphylococcus aureus infection which is associated with the severity of hand eczema. Incidences of allergic diseases including hand eczema and chronic itch are higher in patients with human immunodeficiency virus. Pruritus is one of the most common symptoms in hand eczema, sometimes intractable pruritus provokes repeated scratching, picking, disfigurement, and can even worsen the lesion. Currently, there is no ideal treatment for hand eczema, the treatment of hand eczema in human immunodeficiency virus patients is even more difficult. Here, we present a case of recurrent and therapy-resistant hand eczema patients combined with Staphylococcus aureus infection, human immunodeficiency virus infection was better improved by being treated with topical ozone therapy.

Introduction

The present case reports a 46-year-old man who was referred to our department because of a year-long history of pruritic rash, symmetrical erythema, scale, fissure, and pustules on the hands and wrists (Figure 1(a)). He had a 3-year history of human immunodeficiency virus (HIV) infection and no history of allergic diseases. The patient had no history of contact with irritating substances. Physical examination revealed diffuse edematous erythema with dry scales covering both palms and wrists, scattered and distributed by yellow pustules, linear fissure, and small pieces of erosion. The patient had unbearable itch and pain which affected his normal life and sleep. Laboratory tests revealed eosinophil ratio was elevated to 9.7% (0.4–8), C-reactive protein concentration (CRP) was increased at 15.99 mg/L (0–10), immunoglobulin E (IgE) levels were 1104.86I U/ml (0–100 IU/ml), IL-10 was 5.61 pg/ml (0–4.91), and IL-6 was 7.82 pg/ml (0–5.30). Bacterial cultures of pustules taken from both hands showed Staphylococcus aureus colonization. However, the result of fungal culture is negative. Histology indicated (Figure 1(a)) excessive keratinization with incomplete keratinization, pustules in the stratum corneum, local sponge edema in the epidermal and infiltration by lymphocytes, dermal papillary edema, and lymphocytes and eosinophils infiltration in the upper dermis (Figure 2). The diagnosis was hand eczema with S. aureus infection based on the physical examination and pathology result.

Figure 1.

(a) Hand eczema before treatment. (b) After 3-day treatment of topical ozone therapy. (c) After 9-day treatment of topical ozone therapy.

Figure 2.

A biopsy of the right hand showed the presence of local sponge edema in the epidermal and infiltrated lymphocytes, lymphocytes, and eosinophils infiltrated in the upper dermis.

The patient was first treated with topical steroids, mupirocin cream, and moisturizing lotion and showed transitory improvement but the condition worsened when the treatment was discontinued with no clear triggering factors. Since topical treatment could not control the condition and the improvement gap was getting shorter, oral medicines including antihistamine, tripterygium glycosides, and erythromycin capsules were used but still had poor therapeutic response. Then the patient was treated by diprospan injection once a month. During the injection period, the lesion was partially reduced, but once the injection stopped, the lesion became even more severe than before. Then we tried ozone therapy for the patient. First, we used a 3.0 mg/L concentration of ozonated water under 20°C over 9 days of therapy (20 min every day). The ozonated water was generated by the HZ-2601B Ozone Water Generating Instrument. Then we sprayed the 100 g/L dose of ozone oil on the lesion, and moisturizing cream was applied externally several times a day after the ozone hydrotherapy. After the 3-day treatment, the lesion was markedly improved (Figure 1(b)), with most of the pustules subsiding and the scale decreased. Nine days later, the erosion surface and fissure healed, pustules disappeared, and swelling of the hands and wrists was greatly decreased (Figure 1(c)). Although the lesion did not return to the normal state, the pain subsided and itchiness significantly reduced. We advised the patient to continue to use the moisturizers. The lesion did not recur after 3 months of telephone follow-up.

HIV patients prove to have an imbalance of Th1/Th2. The Th1 cytokines in serum (IL-2, IFN-γ) declined and Th2-related cytokines (IL-4, IL-10) increased, which shows the immunologic predisposition toward a Th2 phenotype or atopy. ⁷ At the same time, elevated IgE levels and hyper-eosinophiliain in HIV-infected patients have been confirmed; therefore, there is a significantly increased incidence of allergic disease especially atopic dermatitis in which the incidence rate even rises to 50%. ⁷ Our patient has an increased level of IL-10 and IL-6. This also confirms that the patient’s immunologic skewing toward a Th2 phenotype and the high level of IgE in serum indicates the patient is in a severe allergic state.

Because of the immunological characteristics of HIV-positive patients, the treatment may be more difficult than for HIV-negative patients. First, low-dose ozone has been demonstrated to possess strong oxidizing properties, making it effective against fungal, viral, and bacterial agents. The topical application of ozone therapy can eliminate 100% of S. aureus in 5 min.^8,9 Second, low-dose ozone can accelerate wound healing and promote skin repair. ¹⁰ Third, it also plays a role in immune system regulation during disease treatment. So ozone therapy was widely used in clinical therapy.^11,12 Given the inflammation, S. aureus infection, skin barrier dysfunction, and resistance to traditional therapies observed in our patient, we chose the use of ozonated water and ozonated oil for the treatment of this patient. Although dupilumab demonstrated effectiveness and safety in the treatment of atopic dermatitis, our patient refused to use it due to its high cost. The result conferred the combination of topical ozone therapy and moisturizing cream has great improvement in a short time, which not only significantly improves clinical manifestations but also greatly reduces pain and pruritus. Furthermore, the topical use of ozone therapy avoided the side effects of glucocorticoids or other immunosuppressants.

The limitation of our report is that we did not check the change in Th2-related cytokines, IgE, and CRP after treatment. Further studies are needed to investigate the difference in ozone therapy in HIV-positive and HIV-negative patients with HE.