Use of Potassium Hydroxide (KOH) Test Reduces Antifungal Medication Prescription for Suspected Monilial Diaper Dermatitis in the Neonatal Intensive Care Unit: A Quality Improvement Project.

BACKGROUND: Despite availability of rapid fungal potassium hydroxide (KOH) tests, many care providers rely on visual assessment to determine the diagnosis of monilial diaper dermatitis (MDD). PURPOSE: To determine whether a KOH test, when MDD is suspected, would result in more accurate diagnoses, with decreased antifungal medication prescription and exposure. METHODS: Quality improvement project from 2016 through 2017 with protocol implemented in 2017 for treatment of MDD after positive KOH testing. If monilial rash suspected, after 2 negative KOH tests, then antifungal ordered (considered false negative). χ testing and cost determination were performed. SAMPLE: Neonates in 2 level III neonatal intensive care units. OUTCOME VARIABLES: KOH test results, use of antifungal medication, and cost. RESULTS: The patient census included 1051 and 1015 patients in the year before and after the protocol initiation. The medical orders for antifungal medication decreased from 143 to 36 (P < .001; 95% odds ratio confidence interval, 2.24-4.38). There was a 75% reduction in both use and cost, as charged, of antifungal agents. Overall charges, including KOH test costs, decreased by 12%. Three infants received multiple negative KOH tests, then a positive one. These met the definition of false-negative tests, per protocol. There were no cases of fungal sepsis. IMPLICATIONS FOR PRACTICE: Use of a quality improvement protocol, in which the use of KOH testing is required, before antifungal agents are prescribed, results in decreased exposure and costs. IMPLICATIONS FOR RESEARCH: To test the feasibility of bedside "point-of-care" KOH testing, and whether KOH testing and reduced antifungal medication use affects antimicrobial resistance or invasive fungal sepsis.

Infection and tissue repair of experimental cutaneous candidiasis in diabetic mice.

PURPOSE: Diabetic patients seem to be predisposed to cutaneous candidiasis. In this study, we evaluated the interference of diabetic conditions in alloxan-induced diabetic mice in relation to the development of C. albicans infection, density of M1 and M2 macrophages, distribution of collagen type I and III and anti-inflamamatory cytokines involved in tissue repair. METHODOLOGY: The mice were treated with intravenous alloxan, and all animals with blood glucose levels >250 mg dl-1 were inoculate with C. albicans intradermally in the hind paw and were studied for up to 21 days. Control groups without alloxan were used. The fungal burden was evaluated by periodic acid-Schiff (PAS) and by counting the colony forming units. Total population of macrophages were targeted with antibody to F4/80 antigen and M2 macrophages with anti-arginase antibody. Anti-inflammatory cytokines from popliteal lymph nodes were determined by capture ELISA procedures. Picrosirius red staining allowed qunantification of collagen types I and III in the infected skin by using a polarized light microscope.Results/Key findings. Diabetic mice, versus non-diabetic mice, showed a significant lower density of F4/80 and M2 macrophages, higher fungal burden, deficiency in interleukin (IL)-4 production, and delayed IL-13 responses. The later clearance of C. albicans enhanced tissue injury, leading to a decrease in collagen type I. Moreover, collagen type III was increased by interference of IL-13 and transforming growth factor-ß cytokines. CONCLUSION: These findings highlight some important changes in diabetic animal responses to C. albicans infection that may be important to the pathophysiological processes underpinning cutaneous candidiasis in diabetic patients.

Differential Diagnosis of Diaper Dermatitis.

Mild diaper dermatitis often occurs in children before toilet training is complete, particularly from 9 to 12 months of age, and the most common presentation is an irritant contact dermatitis. Diaper dermatitis may account for up to 25% of dermatology visits to health care providers during the first year of life. Fortunately, since the introduction of hypoallergenic, superabsorbent modern disposable diapers, the incidence and severity of irritant and allergic contact dermatitis has decreased dramatically. Diaper dermatitis broadly refers to skin disorders that occur in the diaper area, such as skin eruptions triggered by diapers, rashes exacerbated by the diaper, and other events that occur in the diaper area. A number of skin conditions that can occur anywhere on the skin may present with distinctive findings in the diaper area. The following discussion will review the most common triggers of diaper dermatitis and contact irritant dermatitis, while focusing on the skin conditions that may be associated or overlap clinically with contact dermatitis.

[Clinical problems in medical mycology: Problem number 48]. / Problemas clínicos en micología médica: problema número 48.

We present the case of a 42-year-old man, HIV-positive, with low CD4(+) T cell count (31 cells/µl), who was admitted to Hospital de Infecciosas F. J. Muñiz in Buenos Aires (Argentina) due to a severe lower back pain. He had a history of several highly active antiretroviral therapy treatments and he also had diabetes and chronic B and C viral hepatitis. A spinal cord CT scan showed two lytic bone lesions in L2 and L3. A bone biopsy was carried out and its microbiological study allowed the isolation of a methicillin-resistant Staphylococcus aureus. Intravenous vancomycin was prescribed, together with a corset and physical rest. A few days later the patient presented with acute dermatitis with papules, vesicles, scales and erythema, which spread over the whole lumbar region. The mycological study of the scales led to the isolation in culture of Candida albicans and Candida parapsilosis. With the diagnosis of decubitus candidiasis he was initially treated with a topical ointment containing 3% salicylic acid and 6% benzoic acid, but only slow, partial improvement was observed. The treatment was changed to oral fluconazole at a daily dose of 200mg. With the latter the patient showed a rapid, complete clinical response.

Concurrent subcutaneous candidal abscesses and pulmonary cryptococcosis in a patient with diabetes mellitus and a history of corticosteroid therapy.

A 50-year-old man with a history of long-term corticosteroid treatment following adrenalectomy for Cushing's syndrome and uncontrolled diabetes mellitus was admitted for an examination of an abnormal thoracic shadow. Cryptococcal serum antigens were positive, and the histopathology of a lung biopsy showed encapsulated yeast resembling Cryptococcus neoformans. On admission, the serum ß-D-glucan level was approximately twice the cutoff value, several nodules were observed on both legs and magnetic resonance imaging revealed subcutaneous abscesses. Candida albicans was identified from needle aspirates, and the patient was successfully treated with fluconazole and flucytosine. We herein report the first case of concurrent C. albicans skin abscesses and pulmonary cryptococcosis.

Primary cutaneous Candida tropicalis infection in a patient with B-cell lymphoma.

We report the case of a 61-year-old man with diffuse large B-cell lymphoma who presented with a tender skin lesion on the left side of the flank of 5 weeks' duration after undergoing myeloablative chemotherapy. Prior treatment with intravenous vancomycin showed minimal response. Clinical examination revealed a tender, indurated, erythematous plaque on the left side of the flank. A skin biopsy demonstrated a lymphohistiocytic and neutrophilic infiltrate with deep dermal necrosis and fungal forms in the dermis and subcutis. A tissue culture grew Candida tropicalis; however, blood cultures remained negative for yeast. A diagnosis of primary cutaneous candidiasis was made based on the lack of response to antibiotics, tissue evidence of C tropicalis, and negative blood cultures. Although rare, primary cutaneous candidiasis should be considered in immunocompromised patients presenting with cellulitis or an abscess that is unresponsive to treatment.

[Diaper dermatitis]. / Windeldermatitis.

Diaper dermatitis is one of the most common skin diseases during infancy and childhood. It is a type of irritant contact eczema resulting from a complex interaction between urine and feces under occlusive conditions in combination with the hyperhydration of the stratum corneum, pressure and friction under the diaper. These conditions pave the way for Candida albicans infection, which is often associated with diaper dermatitis. The anogenital region can be involved by a variety of dermatoses, so a precise skin examination, detailed history and sometimes histologic examination are needed for a precise diagnosis. Therapeutically, frequent diaper changes and adequate skin care are most important.

Skin interaction with absorbent hygiene products.

Skin problems due to the use of absorbent hygiene products, such as diapers, incontinence pads, and feminine sanitary articles, are mostly due to climate or chafing discomfort. If these conditions are allowed to prevail, these may develop into an irritant contact dermatitis and eventually superficial skin infections. Skin humidity and aging skin are among the most significant predisposing and aggravating factors for dermatitis development. Improved product design features are believed to explain the decline in observed diaper dermatitis among infants. Where adult incontinence-related skin problems are concerned, it is very important to apply a holistic perspective to understand the influences due to the individual's incontinence level and skin condition, as well as the hygiene and skin care measures provided. Individuals with frail, sensitive skin or with skin diseases may preferably have to use high-quality products, equipped with superabsorbent polymers and water vapor-permeable back sheets, to minimize the risk of skin complications.

Isotopic response of fungal granuloma following facial herpes zoster infections - report of three cases.

BACKGROUND: An isotopic response is the occurrence of a new skin disease at the site of another unrelated, healed skin disorder. METHODS: We report three cases of unilateral granulomatous fungal infection in immunocompetent patients at sites of resolved herpes zoster on the face. Diagnoses were made by potassium hydroxide preparation, histopathologic findings, and fungal culture. Two patients had Candida albicans folliculitis, and the other was infected with both Epidermophyton floccosum and Trichophyton mentagrophytes. RESULTS: The patients responded well to antifungal therapy. CONCLUSIONS: Localized isotopic fungal infections, although rare, can occur in immunocompetent patients.

[A case of disseminated candidiasis as an initial presentation of AIDS].

A 44-year-old woman referred for skin eruptions and an altered mental status was confirmed to have HIV infection on Western Blot analysis. Her CD4+ T cell count was 15/microl. On admission, she appeared quite ill with respiratory distress. Chest X-ray showed bilateral patchy infiltration and pleural effusions. She was treated with cefotaxime, pentamidine, and antituberculosis drugs, but her condition worsened and dopamine was initiated. Intensive treatment failed, and she died the following day. An autopsy showed purplish papules on her face and trunk and multiple white nodules in her liver, spleen and lungs. Culture was positive for Candida Albicans, yielding a diagnosis and of disseminated candidiasis. It is rare for HIV patients to be diagnosed with disseminated candidiasis, since the pathogenesis usually requires disruption of the mucosal barrier. The defense mechanism against disseminated candidiasis is mainly neutrophils and macrophages, and its dysfunction is not a primary characteristic of HIV infection. To the best of our knowledge, this is the first report in Japan of a HIV patient to have disseminated candidiasis.

Prospective aetiological study of diaper dermatitis in the elderly.

BACKGROUND: The different causes of diaper dermatitis (DD) in the elderly are not well known and the treatment is often empirical. OBJECTIVES: To determine the causes of DD in the elderly and to evaluate the efficacy of antifungal treatments in this indication. METHODS: Consecutive patients presenting with DD were included. Clinical evaluation, skin swabs for bacterial and mycological cultures, patch testing and skin biopsy were performed at inclusion. This was followed by 1 month of topical antifungal cream and, if needed, by oral fluconazole for the second month. RESULTS: Forty-six patients were included (mean age 85 years). Causes of DD were established for 38 patients: 24 had candidiasis (63%), six irritant dermatitis (16%), four eczema (11%) and four psoriasis (11%). After 2 months of treatment, 27 of 37 (73%) patients were cured and five of 37 were improved. CONCLUSIONS: Mycoses and irritant dermatitis are the main causes of DD in the elderly, and emollient skin care and topical antifungal treatment can be considered a first-line therapy for this indication.

An overview of dermatological conditions commonly associated with the obese patient.

Obesity is a chronic disease that may lead to skin problems, including acanthosis nigricans, skin tags, hyperandrogenism, striae distensae, plantar hyperkeratosis, and candidal intertrigo. Although some conditions (eg, skin tags and striae distensae) may simply be annoying or present cosmetic issues, conditions such as acanthosis nigricans and hyperandrogenism may be indicative of systemic diseases. Obesity also may contribute to poor healing of acute and chronic wounds that develop in this population. Some of the most common obesity-related skin disorders and factors affecting wound healing are described with suggestions on how to address these issues. With the continuing increase in the incidence of obesity, investigation into the specific care needs of this population is needed. In clinical practice, measures to reduce friction and shear and improve devices to move the obese patient would enhance care provision. Studies of the incidence of dermatological problems and the best treatments for these conditions are warranted.

Etiologic and causative factors in perianal dermatitis: results of a prospective study in 126 patients.

BACKGROUND: Perianal dermatitis is probably the most common cutaneous disorder of the genitoanal area. Studies on the epidemiology of causative factors are rare. METHODS: Over a 4-year period we prospectively studied 126 patients with a presumptive diagnosis of anal eczema. The diagnostic algorithm comprised medical history, inspection, microbiology, laboratory chemistry, patch tests, proctoscopy, and biopsy if appropriate. RESULTS: The age range was 7-82 years and the majority of patients were male (57.1%). Periods of anal symptomatology ranged from 6 days to 120 months and most of the patients (51.6%) had complaints for more than 12 months. The clinical diagnosis in 68 patients (54%) was: intertrigo/candidiasis (42.9%), atopic dermatitis (6.3%), pruritus ani (5.6%), psoriasis (3.2%), skin atrophy from steroid use (2.4%), lichen sclerosus et atrophicus (n = 2), herpes simplex (n = 1), and condylomata acuminata (n = 1). Contact eczema was suspected in 58 patients (46%), but 25 of these (43.1%) showed no contact sensitization. CONCLUSION: The majority of patients with symptoms of anal eczema suffer from intertrigo/candidiasis, and relevant, causative contact sensitization may be found in only some of them. Patch-testing is a valuable investigative tool only when the patients' own products are included in the test series. Most patients suffer from their perianal complaints for more than 12 months, therefore diligent evaluation is warranted.

[Nail susceptibility to fungal infections in patients with hypothyroidism and hyperthyroidism]. / Podatnosc paznokci na zakazenie grzybicze u chorych z niedoczynnoscia i nadczynnoscia tarczycy.

Onychomycosis is a frequent disorder in adults. The objective of the study was evaluation of finger and toe nails susceptibility to Candida albicans and a dermatophyte Trichophyton mentagrophytes infection in patients with symptomatic hypothyroidism and hyperthyroidism as compared with healthy persons. The materials comprised finger and toe nails from 23 patients with hypothyroidism (in 8 cases postoperative, and in 15 cases caused by Hashimoto type thyroiditis), and from 27 patients with hyperthyroidism (including 17 cases of Graves-Basedow disease, and 10 with nodular goitre). Nails from 22 healthy persons of similar sex and age distribution served as controls. A significantly more frequent and more intensive than in control group toe nail infection with C. albicans was found in the patients with both hypothyroidism and hyperthyroidism. The enhanced toe nail susceptibility to C. albicans infection did not depend on autoimmunological aetiology of both hypothyroidism and hyperthyroidism.

'Decubital candidosis': a study of 26 cases.

BACKGROUND: Candidoses are infections caused by yeasts of the genus Candida. 'Decubital candidosis' is a particular form of cutaneous candidosis that occurs on the dorsal skin of chronically bedridden patients; there are very few studies about this presentation in the medical literature. OBJECTIVE: To study the clinical, mycological and histopathological features of 26 cases of 'decubital candidosis' along with factors that may predispose to it. METHODS: Twenty-six patients were included and their general characteristics and clinical lesions were carefully studied. The presence of candidosis in other organs and the occurrence of predisposing factors were searched by reviewing the medical records. Mycological studies were performed and cutaneous biopsies were taken. RESULTS: Median age of patients was 46 years, 11 were male and 15 were female, 25 were caucasian, one was Asian and no one was Afro-Carribean. This finding suggests a greater resistance of Afro-Carribean skin to this form of candidosis. The median time of hospitalization until rash occurrence was 24.8 days. Clinical lesions consisted of erythema, erosions, pustules, papules and desquamation. The most significant predisposing factors for this eruption were prolonged bedrest and broad-spectrum antibiotics. Candidosis on other body sites was diagnosed in 10 cases and additional specific predisposing factors were observed in all 10. Potassium hydroxide examination was a reliable test for diagnosing this disease. Candida albicans was the agent in all 26 cases. Spongiform pustules were the most significant histopathological findings and yeasts were restricted to the horny layer in all biopsied cases. CONCLUSION: 'Decubital candidosis' is probably induced by prolonged bedrest and facilitated by long-term use of antibiotics. This cutaneous infection does not seem to predispose to systemic candidosis.