Leg ulcers caused by deep mycotic infection

Leg ulcers causing deep mycosis following fungi are encountered in temperate and tropical climates. They are usually asymetrical, and are located over trauma-prone areas of the legs. The ulcers are usually asympatomatic and insidious at onset. They are often confined to certain geographic regions; sporadic cases have, however, been seen elsewhere. The common deep mycoses causing leg ulcers are mycetoma, sporotrichosis, chromomycosis, and blastomycosis. Histoplasmosis and lobomycosis may occasionally produce bizarre leg ulcers. The causative fungus in them may either be identified through smears/histopathologic sections or on culture.     

Itraconazole pulse therapy for the treatment of Candida onychomycosis

In this open label, multicentre trial, 44 patients with clinical and mycological evidence of Candida onychomycosis were treated with itraconazole pulse therapy. Onychomycosis of the toes alone and concomitant disease involving the fingers and toes was treated with three pulses, and onychomycosis of the fingers alone with two pulses. Final evaluation for patients with finger and toe onychomycosis was at 6-9 months and 9-12 months, respectively. There were 29 patients with toe onychomycosis (C. albicans, 27; C. glabrata, one; Candida species, one), 12 patients with finger onychomycosis (C. albicans, two; C. glabrata, one) and three patients had combined toe and finger onychomycosis (C. albicans, two; C. guillermondii, one). In the patients with toe onychomycosis mycological cure was observed in 29 of 32 patients (90.6%). There was complete cure [mycological cure (negative culture and KOH at endpoint evaluation) with clinical cure] or marked improvement (mycological cure with 75% or greater decrease in area of involvement of target nail compared with pretherapy) in 24 of 32 patients (75.0%). All 12 patients with finger onychomycosis alone due to Candida species achieved a mycological cure (100%). In this group of patients complete cure or marked improvement was observed in 11 of 12 patients (91.7%). Itraconazole pulse therapy was well tolerated and no serious adverse events were reported in the patients treated with this triazole. In conclusion, itraconazole pulse therapy is an effective and safe treatment for both finger and toe onychomycosis associated with Candida.     

Chromomycosis caused by Exophiala spinifera

Chromomycosis is a chronic, localized infection of the cutaneous and subcutaneous tissues caused by dematiaceous fungi of several genera. It has distinctive clinical, pathological and mycological characteristics. Exophiala spinifera is a well-established aetiological agent of phaeohyphomycosis, but there are only two reported cases worldwide of this dematiaceous fungus causing chromomycosis. We report the first known case in the UK of E. spinifera causing chromomycosis.     

Intense pulsed light in the treatment of non‐aesthetic facial and neck vascular lesions: report of 85 cases

Background Intense pulsed light (IPL) treatment is one of the most effective procedures for patients with non‐aesthetic vascular lesions in addition to signs of skin photoageing, and it has been reported as very successful in the treatment of telangiectasias, spider nevi, erythrosis, and above all, rosacea and poikiloderma. Its use is based on the principle of selective photothermolysis, which exploits the haemoglobin absorption peak among its range of wavelengths. Objective The aim of this study is to assess the efficacy and safety of intense pulsed light in treating non‐aesthetic vascular skin lesions, especially with regard to poikiloderma of Civatte and rosacea. Methods A total of eighty‐five patients, 64 women and 21 men, with 63 non‐aesthetic vascular lesions (28 Poikiloderma of Civatte and 35 rosacea), 22 pigmented lesions (UV‐related hyperpigmentation of solar lentigo‐type) and four precancerous lesions (actinic keratosis, AKs), were treated repeatedly with IPL for 2 years. The patients received a mean of five treatments (range 4–6) at 3‐weekly intervals. They were evaluated via clinical observations and professional photographs were taken before each treatment and after 2 weeks, 4 weeks, 3 months, 6 months and 12 months. The outcome of the IPL treatments was evaluated by four independent dermatologists, who were not informed about the study protocol, and who assessed the performance of IPL by dividing the results into four categories: no results, slight improvement, moderate improvement and marked improvement. Results All the patients showed improvements in their overall lesions: 72 lesions (80.9%) achieved a marked improvement, 14 lesions (15.7%) achieved a moderate improvement and three lesions (3.4%) achieved a slight improvement. The results of the 63 non‐aesthetic vascular lesions in Rosacea and Poikiloderma of Civatte were: 51 with a marked improvement, 10 with moderate improvement, whereas only two lesions achieved a slight improvement. The improvement of all four actinic keratoses was marked whereas the 22 pigmented lesions obtained a marked improvement in 17 cases, a moderate improvement in four cases and a slight improvement in one case. No undesirable effects were observed. Conclusions Our study confirms how by minimizing side‐effects, time and costs, IPL can be effective and safe for the treatment of non‐aesthetic facial and neck vascular lesions.     

Mycetomas in central Tunisia

INTRODUCTION: Mycetomas are inflammatory pseudo-tumors containing fungal or actinomycosic-type grains. They are frequent in tropical and subtropical countries and unknown in Tunisia. PATIENTS AND METHODS: We conducted a retrospective study of 12 cases of mycetoma registered in the Dermatological department of the university hospital in Sousse (central Tunisia) over a period of 27 years, from 1974 to 2001. The diagnosis was confirmed by anatomopathological and/or mycological examination. RESULTS: The mean age at the onset was of 49 years and the sex ratio of 1. A notion of a traumatism was reported in two cases and eight patients had various agricultural activities. The mean duration of progression was of eight years. The localization was the foot in 10 cases. The mycetoma was of actinomycosic origin in 10 cases, due to Actinomadura madurae in nine cases, to Nocardia spp in one case and of fungal origin in 2 cases:Pseudoallescheria boydii in one case and Madurella mycetomi in the other. Antibiotic therapy was associated with surgical exeresis in nine cases and amputation in the other two cases. COMMENTS: Confrontation of our results with those of Tunisian series and a review of the literature, helped to specify the clinico-epidemiological characteristics and progression of mycetoma in Tunisia. These characteristics are: the rareness of the infection, the relative frequency of affection in women, the proximal involvement of the foot, the frequency of agricultural activity and the rareness of traumatic past history, the predominance of the actinomycosic origin due to Actinomadura madurae, and the need to associate surgical exeresis with the medical treatment or amputation in order to stop the progress of the disease.     

Sulconazole nitrate 1.0 percent cream: a comparison with miconazole in the treatment of tinea pedis and tinea cruris/corporis

Sulconazole nitrate 1.0 percent cream was compared to miconazole nitrate 2.0 percent cream in a double-blind, parallel study involving ninety-six patients with cutaneous dermatophytosis. Both agents were highly effective, with no statistically significant differences in the parameters studied. Among tinea pedis patients, all of seven treated with sulconazole and six of nine treated with miconazole were mycologically cured (negative culture and potassium hydroxide test) at the end of four weeks of twice a day treatment, and there were no relapses by week 9. Among tinea cruris/corporis patients, the rates of mycological cure after three weeks of twice a day treatment with sulconazole or miconazole were, respectively, twenty-nine of thirty-two (91 percent) and 100 percent of thirty one (accompanied in all cases by complete or significant clearing of signs and symptoms); the respective relapse rates were four of twenty-five (16 percent) and eight of twenty-three (35 percent). Miconazole resulted in two cases of severe irritant dermatitis requiring discontinuation of treatment, whereas sulconazole produced no severe irritant reactions.     

Resolution of oral lichenoid lesions after replacement of amalgam restorations in patients allergic to mercury compounds

The significance of contact allergy in patients with various oral symptoms was studied. Positive patch-test reactions to mercury compounds were found in 21/91 patients. Of these, 18 had lichenoid lesions in oral mucosa in close contact to amalgam fillings, and three patients with contact allergy had neither amalgam fillings in their teeth nor visible oral lesions. Amalgam replacement was carried out in 15/18 symptomatic patients. The fillings were replaced with gold in three cases, composite resin fillings in six, glass ionomer in three and both gold and composite materials in three cases. In 10 patients there was complete replacement and in five it was restricted to the fillings adjacent to the mucosal lesions. After a mean follow-up period of 3.2 years a complete cure was seen in seven patients, each of whom had had all their fillings changed. A marked improvement occurred in six patients, and there was no change in two.     

Itraconazole pulse therapy is effective in the treatment of tinea capitis in children: an open multicentre study

In an open multicentre study we have demonstrated that itraconazole pulse therapy, 5 mg/kg per day, is effective and safe in the management of tinea capitis in 10 children (seven boys, three girls, mean age: 6.6 years, age range 4–11 years). The causative organisms were Trichophyton tonsurans (six cases), T. violaceum (two cases), T. soudanense (one case) and Microsporum gypseum (one case). Each pulse of drug therapy lasted 1 week with 2 weeks off between consecutive pulses. One, two and three pulses produced complete, clinical and mycological, cure in one, six and three patients, respectively. The children tolerated the treatment well and there were no clinical or laboratory adverse effects. This 1-week pulse therapy regimen resulted in a high degree of compliance. The preliminary results of this study are promising and need to be evaluated in a larger sample of patients.     

Italian multicentre study with oral itraconazole in recurrent pityriasis versicolor, Preliminary report

Pityriasis versicolor is a common mycosis, characterized by frequent recurrences. Oral itraconazole is very effective in the treatment of this infection but there are no published studies on its prophylactic use. The purpose of our study was to assess further the efficacy of itraconazole in the treatment of recurrent pityriasis versicolor and to investigate its role in prophylaxis. In this ongoing study, 270 patients with recurrent pityriasis versicolor receive 200 mg itraconazole once daily for seven days. Those who experience clinical and mycological cure, sustained one month after the end of treatment, then enter the prophylactic phase of the study and receive either 200 mg itraconazole or two placebo capsules once a month for five months. Of the 48 patients who so far have received the full seven days' treatment with itraconazole, 31 have completed the first phase of the study. Complete clinical cure was achieved in 30(96%) and residual lesions persisted in one. Mycological cure was achieved in all. No adverse events were reported. Nine patients have now entered the prophylactic phase (five taking itraconazole and four placebo). No symptoms so far have reappeared in any of them. Oral itraconazole is a highly effective and well-tolerated treatment for recurrent pityriasis versicolor. The role of itraconazole in prophylaxis is still undetermined pending completion of the study.     

TREATMENT OF EUMYCETOMA WITH KETOCONAZOLE

Ten patients with eumycetoma were treated with oral ketoconazole in the dosage of 400mg/day for 8 to 24 months. In eight cases the foot was affected: four were due to Madurella mycetomatis and one each due to M grisea, Pyrenochaeta romeroi, Acremonium kiliense and A falciorme. One mycetoma which affected the back and perineum was due to A kiliense, and one case presented with multiple sebaceous cysts and the scalp and M mycetomatis was isolated from the lesion. Clinical and laboratory tests showed excellent tolerance to the drug, with no adverse reactions. Complete cure was obtained in six patients and two showed good responses. The cured patients were followed up for a period ranging from three months to two years without any evidence of recurrence.     

PERSISTENT VIABILITY OF THE MEDLAR BODY

Background. The Medlar body represents an adaptive tissue form of the fungi known to cause cutaneous chromomycosis. This study was designed to determine the in vitro viability of Medlar bodies that are found in profusion within lesional epidermis. Methods. Epidermal scrapings of three indigenous cases from Texas of chromomycosis due to Fonsecaea pedrosoi were collected and periodically cultured to determine the duration of fungal viability. Results. The causative organism could be recovered 11, 15, and 18 months, respectively, after epidermal scrapings were obtained from the three patients. Conclusions. This simple but important experiment indicates that Medlar bodies are quite hardy. Thus, clinical lesions may appear after long incubation periods subsequent to traumatic implantation of etiologic fungi. The robust adaptability of the tissue form may also account for the difficulty in achieving a “cure” in cases of chromomycosis.     

Mycetoma with black granules: first case in a native of Israel]

We present a case of black grain mycetoma caused by Madurella mycetomatis. The diagnosis was made on the basis of conventional light microscopy and mycological studies. After 12 months of oral therapy with ketoconazole, the patient showed partial response. This is the first native Israeli case of black grain mycetoma.     

Q-switched Nd:YAG laser versus itraconazole pulse therapy in treatment of onychomycosis: A clinical dermoscopic and mycologic study

Background

Onychomycosis (OM) represents about 50% of nail disorders. Oral antifungals have proven efficacy in the treatment of onychomycosis but their associated side effects limit their use. Accordingly, there is an increased need for a safe and effective therapy to induce clearance and improve the esthetic appearance of diseased nails.

Objective

The current study is an attempt to evaluate and compare the efficacy of Q-Switched Nd:YAG (1064 nm) laser as monotherapy versus pulse itraconazole in the clearance of onychomycosis.

Methods

In this prospective study, 40 onychomycosis patients were equally divided into two groups: Groups I (laser group) and II (Itraconazole group). Patients of Group I are treated with six biweekly sessions of Q-Switched Nd:YAG (1064 nm) laser. Patients of Group II are treated with itraconazole pulse therapy. The assessment of clearance was rated using the “Onychomycosis Severity Index (OSI)”, photographs, dermoscopy, and mycology. All 40 patients were followed up for 3 months after the end of treatment.

Results

Group I's clinical improvement response was a marked improvement in 19 cases and moderate improvement in one case (OSI before treatment was 24.5 and after was 0). A dermoscopic cure occurred in 19 cases. Mycological cure was obtained in 19 cases. Group II's clinical improvement response was marked in 15 and moderate in 5 (OSI before treatment was 24 and after was 0). Dermoscopic cure occurred in 15 cases. Mycological cure was obtained in 15 cases. There were no adverse effects. The clinical response, the dermoscopic cure, and the mycological cure were equal in both groups, with no significant difference found between them.

Conclusion

Q-Switched Nd:YAG (1064 nm) laser can be used as an effective and safe modality in the clearance of nail onychomycosis, particularly in patients who have a contraindication to or refuse the use of oral antifungals.     

Intralesional triamcinolone injections for the treatment of nail dystrophy: A case series

Nail dystrophy can be temporary or permanent and affects quality of life for many patients. It can be secondary to an inflammatory condition; however, many cases are idiopathic. Despite many efforts, there is no promising treatment. Local steroid injection is one of the standard therapies offered for nail dystrophy, but there have been few formal open trials or case reports of its efficacy. This study investigated the impact of intralesional triamcinolone injections on the management and safety of nail dystrophy. Overall, 12 patients with 55 nails affected by nail dystrophy were enrolled. All lesions were injected with triamcinolone acetonide (2.5 mg/mL, 0.1 cc) through the proximal nail fold with a 30 g needle. Injections were administered every 4 weeks. Efficacy was retrospectively evaluated using physician's global assessment of clinical photographs graded on a 5‐point scale as 0, no improvement; 1, slight improvement; 2, moderate improvement; 3, marked improvement; and 4, almost resolved. All adverse events that occurred during treatment were recorded. All patients presented with slight improvement of nail dystrophy after 1 to 3 months. The treatment durations varied from 6 to 12 months (mean, 8.58 months). The average time to observed therapeutic effect was 1.91 months after first treatment. The mean outcome assessment score was 2.8 points, with two patients each showing slight and moderate improvement and five showing marked improvement; in three, the dystrophy was almost resolved. Side effects of this regimen were minimal. Intralesional triamcinolone injections are an effective and safe method for the treatment of nail dystrophy.     

Pedal interdigital condylomata lata: a rare sign of secondary syphilis

BACKGROUND: Condylomata lata of the toe webs are uncommon manifestations of secondary syphilis. Considering the recent decline in the incidence of syphilis in the United States, such lesions are likely to present infrequently. In some cases, this phenomenon may be the only physical sign of syphilis; therefore, it is important that a high index of suspicion is maintained when evaluating toe web lesions in patients at epidemiologic risk for syphilis. GOALS: A case of secondary syphilis presenting solely with interdigital condyloma lata in the toe web spaces is reported, and similar cases reported in the literature are reviewed. STUDY DESIGN: This article documents the diagnosis of secondary syphilis based on a positive serology in conjunction with the development of interdigital condyloma lata as the only physical finding suggestive of lues. RESULTS: The latter lesions resolved after appropriate, adequate antibiotic therapy. CONCLUSIONS: A case of condylomata lata of the toe webs without other pertinent physical findings is presented. Analogous to lesions typically seen in the anogenital region, moist exophytic toe web plaques may represent condyloma lata and thereby be a sign of secondary syphilis. The differential diagnosis includes tinea pedis, erythrasma, macerated corns, verrucae, and several tropical mycoses (chromomycosis, mycetoma).     

Squamous-cell Carcinoma and Lobomycosis (Jorge Lobo''s Disease)

Among the Cayabi Indians in Central Brazil, we found a high and unexpected prevalence of lobomycosis, which represents 21% of all the cases reported in the world medical literature until now. Most of the Cayabi patients have been observed for many years, and recently two developed cauliflower-like tumours in old lobomycosis scar lesions. The diagnosis of squamous cell carcinoma was confirmed histologically. In both cases, the tumor was surgically removed, but several months later tumors recurred in both patients. The appearance of squamous cell carcinoma in chronic scar lesions and ulcers of various etiologies has been reported by many authors, and should include lobomycosis.     

Dermatomycoses in Indonesia

ABSTRACT: A review of mycologic surveys and case reports indicates the unique occurrence of deep and superficial fungus infections of the skin as encountered in Indonesia, confirming that each country has its own pathogenic mycologic flora. Such diseases as phycomycosis, histoplasmosis, mycetoma, chromomycosis, cryptococcosis, and dermatophytosis are common.     

Cyclosporin A treatment of systemic sclerosis

Ten patients with severe progressive systemic sclerosis were treated with cyclosporin A at dosages of 1.5-7.5 mg/kg per day:two patients showed a marked improvement with softening of the involved skin; in one patient there was healing of persistent digital ulcers; one patient showed initial improvement followed by a marked exacerbation; one patient was slightly improved; two patients were unchanged. The clinical results correlated well with levels of serum aminoterminal propeptide of type III procollagen. In the eight patients completing treatment, side-effects such as slight tremor and a transient increase in the serum creatinine and blood pressure were either absent or reverted to normal when the dosage was decreased, except one case who had to be treated with anti-hypertensive drugs.     

Lobomycosis

Lobomycosis is a rare chronic fungal infection of the subcutaneous tissue found in South America, mainly in Brazil. It is caused by Lacazia loboi. Its clinical manifestations are dermal nodules, either lenticular or in plaques, and keloidlike lesions that can resemble nodular leprosy or leishmaniasis, other subcutaneous mycoses (sporotrychosis, chromomycosis, paracoccidioidomycosis), keloids, and malignant tumors. Diagnosis is made by the histopathological findings of the fungus. For treatment, surgical removal of the lesions, followed by itraconazole and clofazimine for disseminated lesions, has been used with variable results.     

A double-blind, randomized study comparing itraconazole pulse therapy with continuous dosing for the treatment of toe–nail onychomycosis

In this multicentre, double–blind, parallel group study, we evaluated the efficacy and safety of continuous treatment with itraconazole, 200 mg daily for 3 months, in comparison with itraconazole pulse therapy, 400 mg daily 1 week per month for 3 months, in the treatment of toe–nail onychomycosis. The study included 129 patients with distal subungual onychomycosis of the toe–nails, confirmed by microscopy and positive for dermatophyte culture; 65 received continuous treatment and 64 received pulse therapy. Patients were followed up for 9 months after treatment. After 12 months, there were 62 evaluable patients in the continuous group and 59 evaluable patients in the pulse group. The clinical response (i.e. the size of the affected area and the progress of the infection) and mycological cure (i.e. negative results on microscopy and culture) were the main outcome measures. A clinical response was defined as a cure or a marked improvement. Clinical response rates were 69%, in the continuous group, and 81% in the pulse group at month 12; the corresponding mycological cure rates were 66 and 69%. A better improvement in signs and symptoms was noted in the pulse group. Six patients were withdrawn from treatment because of adverse events, not all of which were thought to be drug–related. There were no clinically relevant laboratory abnormalities. We conclude that both regimens are effective, safe and well tolerated. The superiority of one treatment over the other was not established, but the results tended to favour pulse therapy. Equivalence testing confirmed that pulse therapy was at least equivalent to continuous treatment.