Toxic epidermal necrolysis caused by over the counter eyedrops

We present a case of a 15‐year‐old boy who developed toxic epidermal necrolysis (TEN) from sulfacetamide eyedrops. He presented with conjunctival injection and an erythematous rash that rapidly progressed to epidermal necrosis of over 30% of his body. A skin biopsy revealed an acute lichenoid reaction pattern consistent with TEN. After 22 days in hospital, he was left with significant scarring to his eyes, mouth and anogenital areas. An extensive search for an infective aetiology was negative. Previously exposed to bactrim tablets, he used Bleph‐10 eyedrops 3 days before admission to hospital. The patient had a strong family history of sulphur allergy. The onset of TEN after topical administration of medication has been reported rarely in the literature. This case highlights the need for a thorough medication history that includes topical preparations.     

Framing the future of antifungals in atopic dermatitis

Atopic dermatitis (AD) is a frequent chronic inflammatory skin disease. Some fungal colonization or infection of the skin may exacerbate AD severity, particularly the so-called head and neck variant. In addition, excessive intestinal colonization by Candida albicans may represent an additional triggering factor. Hence, there is a rationale to use antifungals in selected AD patients. Early trials with topical ketoconazole in head and neck AD showed a decrease in Malassezia colonization, but no significant improvement was observed in the clinical severity. In contrast, clinical improvement and decreased serum IgE were obtained in patients with positive Malassezia radioallergosorbent tests (RASTs) who were treated by oral ketoconazole. Some preliminary data suggested that oral itraconazole treatment in AD patients reduced the need for topical corticosteroids, provided clinical improvement particularly in head and neck AD, reduced the cutaneous and intestinal fungal colonization that may trigger AD, reduced the percentage of positive Malassezia cultures and demonstrated a decrease in C. albicans and Malassezia RAST values. Furthermore, beside its antifungal action, itraconazole in part relieves pruritus and inflammation. In conclusion, oral itraconazole treatment can alleviate AD severity in selected patients. Fluconazole is also effective. Further research is warranted to identify whether the load in skin surface fungal agents, the fungal RAST values and specific prick testing should be assessed in order to optimize the antifungal management in AD patients.     

120例健康育龄妇女阴道sIgA浓度检测及其与阴道念珠菌感染的关系

用放射免疫法检测了１２０例健康育龄妇女、４１例念珠菌性阴道炎患者和２９例阴道念珠菌带菌者阴道ｓＩｇＡ的浓度。念珠菌性阴道炎组根据白带直接镜检下念珠菌的形态分为两组：以孢子、芽管为主者为念珠菌性阴道炎１组，以菌丝为主者为念珠菌性阴道炎　组。结果表明，健康育龄妇女阴道ｓＩｇＡ浓度范围为２０６．０　１００．１　ｇ／ｍｌ，念珠菌带菌者阴道ｓＩｇＡ与健康对照组无差异。念珠菌性阴道炎　组阴道ｓＩｇＡ低于健康对照组，念珠菌性阴道炎　组则相反。     

白念珠菌对棘白菌素类药物耐药机制的研究进展

【摘要】 随着棘白菌素类抗真菌药物的应用,对其耐药的白念珠菌菌株越来越多。已发现白念珠菌对棘白菌素类药物耐药主要与FKS突变、MSH2突变、ERG3突变及生物膜形成、细胞自身应激反应、几丁质含量增高、膜鞘脂合成等相关。本文综述白念珠菌相关耐药基因及可能的耐药调控机制,有助于临床克服和预防棘白菌素耐药,探索治疗白念珠菌感染的新靶点,开发新药物。     

Malassezia yeasts in the pathogenesis of atopic dermatitis

Atopic dermatitis is a common skin condition, the aetiology of which is multifactorial, involving genetic, immunological and environmental factors. In recent years, it has been suggested that various microbial organisms may also be involved in the pathogenesis of the disease. Yeasts belonging to the Malassezia genus have received particular attention. These yeasts, known to be a part of the normal skin flora, have been shown to be capable of inducing immunoglobulin (Ig)E-mediated and T-cell mediated immune responses postulated to contribute to chronic inflammation in the skin, particularly in the head and neck region, where colonization with Malassezia is the greatest. Considerable evidence now exists to support this idea, raising the possibility that specific antifungal therapy may be a useful treatment measure in some atopic patients who have a head and neck pattern of dermatitis.     

Efficacy and safety of topical antifungals in the treatment of dermatomycosis: a systematic review

The analysis of comparative efficacy and safety of topical antifungals in the literature is restricted to the treatment of tinea pedis and onychomycosis. Therefore our objective was to evaluate and compare the efficacy and safety of topical antifungals used in the treatment of dermatomycosis, we performed a comprehensive search for randomized controlled trials (RCTs) in the following databases: Medline, Cochrane Central Register of Controlled Trials, EMBASE, Lilacs and International Pharmaceutical Abstracts, we identified studies that compared the use of topical antifungals with other antifungals or with placebo published up to July 2010 in English, Spanish or Portuguese. The quality of reporting was assessed according to the Jadad scale; only studies with a score of 3 or more were included. The outcomes evaluated were mycological cure at the end of treatment, sustained cure, occurrence of adverse events and tolerability, including withdrawals due to adverse events. A total of 104 RCTs satisfied the inclusion criteria, containing a total of 135 comparisons, with 55 out of 120 possible comparisons among the 16 drugs evaluated. Pooled data on efficacy showed that all the antifungals were better than placebo. There were no significant differences among antifungal classes. No differences were found in safety or tolerability in any direct comparison. Sensitivity analysis indicated the robustness of the findings. Our results indicate the clear superiority of topical antifungals over placebo but that there is no consistent difference among classes. Mixed treatment comparisons are necessary to rank antifungals, as direct comparisons among many of them are lacking.     

Long-term efficacy of antifungals in toenail onychomycosis: a critical review

BACKGROUND: Modern antifungal drugs achieve high mycological and clinical cure rates in onychomycosis of the toes, but little is known about the long-term evolution of the treated patients. OBJECTIVES: The aim of this review was to analyse the therapeutic results recorded more than 1 year after initiation of therapy. METHODS: We used two endpoints for the analysis: EP1 (the number of patients with negative mycology after follow-up, divided by the number of patients included at day 0, including all patients lost to follow-up), and EP2 (the number of patients with negative mycology after follow-up divided by the number of patients with negative mycology at week 48). Clinical cure rate (EPclin) was the number of patients clinically cured or with minimal residual lesions divided by the number of patients included at day 0. RESULTS: From a Medline search we identified 17 studies providing results beyond 48 weeks. Ketoconazole 200 mg d(-1) up to 1 year resulted in EP1 of 11% at 18 months, and EP2 of 43%. Griseofulvin 1 g d(-1) for 1 year allowed an EP1 of 43% at 18 months, and EP2 of 71%. The mean EP1 after fluconazole once weekly up to 1 year was 49% at 18 months, and EP2 was 91%. With itraconazole 200 mg d(-1) or 400 mg d(-1) for 1 week each month for 3-4 months, EP1 was 37% at 18 months, and 53% at 2 years; EP2 was 76% at 4 years. Terbinafine 250 mg d(-1) for 12-16 weeks achieved an EP1 of 62% at 18 months, 72% at 2 years, and 60% at 4 years; EP2 was 80% at 18 months, 81% at 2 years, and 71% at 4 years. In the only study planned to compare the long-term efficacy of terbinafine and itraconazole, EP1 at 18 months was significantly higher with continuous terbinafine than with intermittent itraconazole (66% vs. 37%, P < 0.001). The clinical cure rates were 21% at 60 weeks and 37% at 72 weeks with fluconazole. EPclin was 27% at 18 months and 35% at 2 years with itraconazole. EPclin was 48% at 18 months, 69% at 2 years and 50% at 4 years with terbinafine. CONCLUSIONS: Considering the stringency of the criteria we used, this critical review suggests that the long-term efficacy achieved with terbinafine is superior to that obtained with griseofulvin, ketoconazole, fluconazole or itraconazole.     

Photoprotection in the era of nanotechnology

Commercial sunscreen based on nano-sized titanium dioxide (TiO(2)) and zinc oxide (ZnO) delivers superior UV protection and reduces whitening on skin compared to the older generations of inorganic sunscreens. This review discusses the historical use of nano-sized TiO(2) and ZnO in sunscreen and the relationship between UV attenuation and the primary particles, aggregates and agglomerates that make up these inorganic oxides. In addition we reviewed the recent safety concerns surrounding these materials, specifically, percutaneous penetration of TiO(2) and ZnO nanoparticles through human skin and their potential to cause phototoxicity.     

Experimental study of the potential for contact sensitization and cross-reaction of imidazole antifungals

We examined the potential for contact sensitization of miconazole nitrate and croconazole hydrochloride and the cross-reaction between them in guinea pigs by the maximization test of Magnusson and Kligman. Contact sensitivity was induced by croconazole hydrochloride in 5 out of 7 animals which, after being injected with 5% croconazole hydrochloride, underwent a closed patch with 25% croconazole hydrochloride. Contact sensitivity was not induced by miconazole nitrate. The 5 animals sensitized to croconazole hydrochloride were tested with 8 other imidazole antifungals and positive reactions were observed to oxiconazole nitrate in 2 of the 5 animals. This response may be a cross-reaction.     

三种抗真菌药物对糖尿病大鼠TLRs和Th细胞因子水平的影响

目的: 测定氟康唑,伊曲康唑和特比萘芬对糖尿病大鼠Toll样受体(TLRs)和辅助性T细胞(Th细胞)细胞因子水平的影响.方法: 建立鼠糖尿病模型,喂食氟康唑,伊曲康唑和特比萘芬4周后,流式细胞术对糖尿病大鼠脾脏T细胞TLR2、TLR4、IFN-γ和IL-4水平进行检测;实时荧光定量PCR (Real-Time PCR)检测TLR4在脾脏细胞中的表达.结果: 氟康唑、伊曲康唑和特比萘芬可以提高糖尿病大鼠TLR2与TLR4的表达水平;伊曲康唑还可提高糖尿病大鼠Th1型免疫应答.结论: 3种抗真菌药物可以通过激发宿主对真菌的天然和获得性免疫应答促进机体对真菌的抵御.     

Erythroderma in the era of biological therapies

Erythroderma is a scaling erythematous dermatitis involving 90% or more of the cutaneous surface. Psoriasis and eczema are the most common dermatoses underlying erythroderma. Cutaneous T cell lymphomas can also cause erythroderma. Differential diagnosis between psoriatic erythroderma and lymphomatous erythroderma is often challenging. Tumour necrosis factor-alpha inhibitors are a new class of drugs used in the treatment of psoriasis, even in erythrodermic psoriasis. The effects of anti-tumour necrosis factor-alpha in cutaneous T cell lymphomas have not yet been established. Consequently, it is mandatory to treat an erythrodermic psoriatic patient with tumour necrosis factor-alpha blockers only if a lymphoproliferative cutaneous disorder has been excluded.