Chlorhexidine Scrub, ZnO Nanoparticles Socks and the Combination for Treatment of Pitted Keratolysis
Chlorhexidine Scrub, ZnO Nanoparticles Socks and the Combination for Treatment of Pitted Keratolysis
This study aimed to study the efficacy of chlorhexidine scrub, zinc oxide nanoparticles
 (ZnO-NPs) socks and the combination of chlorhexidine scrub and ZnO-NPs socks in treatment of
 pitted keratolysis.
Introduction Pitted keratolysis is a common skin disease, caused by various gram-positive
 bacteria including Corynebacterium species, Kytococcus sedentarius, Dermophilus congolensis
 and Actinomyces species. These bacteria create small tunnels in the stratum corneum, causing
 pitted lesions at plantar areas. This condition is frequent accompanied by feet malodor and
 is commonly found in young male adults, especially in soldiers, miners and athletes. The
 reported prevalence of pitted keratolysis among naval cadets in Thailand was 38.7%.
 Predisposing factors related to pitted keratolysis are pedal hyperhidrosis and prolonged feet
 occlusion. Although this condition is generally not painful, our previous study in 2018
 revealed adversely affects patients' quality of life.

 Regarding treatment modalities of pitted keratolysis, various medications and life-style
 modification have been recommended. Previous studies revealed efficacy of topical choices,
 including benzoyl peroxide gel, clindamycin-benzoyl peroxide gel, glycopyrrolate cream,
 erythromycin gel, clindamycin solution, chlorhexidine scrub and mupirocin ointment. Oral
 antibiotics and botulinum toxin injection were also beneficial in pitted keratolysis. As to
 life-style modification, wearing cotton socks and opened footwear, and proper hygiene, have
 also been suggested.

 Zinc oxide (ZnO) has been demonstrated to exhibit antimicrobial activities against many
 microorganisms, such as Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa
 and fungal infections including dermatophytosis. It has been proposed that the mechanism is
 the generation of reactive oxygen species, such as hydrogen peroxide, on microorganism cell
 surfaces, thereby causing membrane dysfunction. The antimicrobial activities have been
 observed to vary with changes in the physical and chemical properties of ZnO, for instance,
 its particle size, porosity and specific surface area.

 Nanobiotechnology , which is the integration of biotechnology and nanotechnology, is
 currently being used in drug delivery systems. The bactericidal efficacy of ZnO nanoparticles
 (ZnO-NPs) has been shown to improves with a decrease in their particle size. ZnO has also
 been shown to be is safe and compatible with human skin, which makes it a suitable additive
 for textiles. Research by Choopong and Sarayut established that ZnO-NP-coated socks exhibited
 antimicrobial activities against gram-positive (S. aureus) and gram-negative (Klebsiella
 pneumoniae) bacteria.

 Objective This study aimed to study the efficacy of chlorhexidine scrub, zinc oxide
 nanoparticles (ZnO-NPs) socks and the combination of chlorhexidine scrub and ZnO-NPs socks in
 treatment of pitted keratolysis.

 Material and Methods First-year naval rating cadets, who had pitted keratolysis were invited
 to enroll in this study. The cadets who previously received any topical treatment including
 topical antibiotic, antiperspirant or aluminum chloride within 6 months prior to the study
 were excluded. Consent was informed and obtained from all participants. Participants were
 assessed for behavioral risk factors and level of foot odor measured by a self-assessed
 visual analogue scale (VAS), using questionnaires. Clinically examination of feet was done in
 all subjects by treatment-blinded dermatologists. Subjects were randomly assigned either
 chlorhexidine scrub, ZnO-NPs socks and the combination of chlorhexidine scrub and ZnO-NPs
 socks for 2 weeks. During the study, using of other topical treatment such as topical
 antibiotics, antiperspirant or aluminum chloride was not allowed. Participants who received
 chlorhexidine scrub were advised to wash their both soles with chlorhexidine scrub two times
 per day in the morning and evening. Participants who received ZnO-NPs socks were asked to
 wear these socks everyday and at least 8 hours per day. All were able to regularly
 participate in physical military training during the study. Two weeks after the treatment,
 clinical examinations by dermatologists and the cadets' self-assessment questionnaires,
 including feet odor by using VAS, treatment satisfaction and adverse effects, were used to
 evaluate the effectiveness. Pitted lesions improvement at plantar areas, evaluated by
 dermatologists, was divided into no improvement, slight improvement (decrease of pitted
 lesions at feet for 1 level) and much improvement (decrease of pitted lesions at feet for at
 least 2 level). Data were analyzed using SPSS version 18 (SPSS, Inc., Chicago, IL, USA).

 Duration of study: 6 months Study design: Randomized control trial
Inclusion Criteria:

 -  First-year naval rating cadets, who had pitted keratolysis

 Exclusion Criteria:

 -  The cadets who previously received any topical treatment including topical antibiotic,
 antiperspirant or aluminum chloride within 6 months prior to the study.