Tinea faciei clinical characteristics, causative agents, treatments and outcomes; a retrospective study in Thailand.

BACKGROUND: Tinea faciei is a relatively uncommon dermatophyte infection. The studies, which included clinical forms, and isolated species of dermatophytes, are limited. MATERIALS AND METHODS: This retrospective study aims to determine the causative organism, clinical characteristics, treatments and outcomes of patients with tinea faciei attending the dermatologic clinic, Siriraj Hospital, from 1 January 2017 to 30 September 2021. Demographic data, clinical presentations, isolated dermatophyte species, treatments and outcomes were collected and analysed. RESULTS: A total of 151 tinea faciei cases were observed. Trichophyton rubrum (48.6%), Trichophyton mentagrophytes complex (22.2%) and Microsporum canis (18.1%) were common causative agents. Tinea faciei was commonly detected in females (64.9%) with a history of pets (54.6%). Clinical presentations often involved plaques and scales on the cheeks. Among patients with lesions on the cheek, mycological cure was observed significantly less often compared to those without cheek lesions. Patients with other concurrent skin or nail infections, a history of topical steroids and a history of previous fungal infection had a slightly longer duration of mycological cure than those without factors. Recurrent infection was found in 33.3%. Male, history of previous fungal infection, and lesions on the cheeks were significantly associated with recurrent infection. CONCLUSIONS: Fungal infection of the face was commonly found in women and patients with pets. The most common pathogen that caused tinea faciei was T. rubrum. Topical antifungal treatments could be used with favourable outcomes. The history of past infection and lesion on the cheeks should be carefully assessed to be vigilant for recurrent infection.

Clinical and Laboratory Characteristics of a Tinea Capitis Outbreak Among Novice Buddhist Monks.

Sixty novice Buddhist monks with tinea capitis confirmed according to clinical presentation and mycological laboratory finding were included in this study. Mixed-type clinical presentation was observed in approximately half of all cases, together with scarring alopecia (95%) and superficial fungal skin infection at locations other than the scalp (43.3%). The major isolated organism was Trichophyton violaceum, and mixed-organism infection was found in 27 cases (45%). Slow-onset presentation and an extensive area of infection were significantly associated with mixed-type clinical presentation.

Prevalence, Risk Factors, and Type of Organism in Fungal Foot Infection and Toenail Onychomycosis in Thai Diabetic Patients.

Background: Diabetes mellitus (DM) is a known and important predisposing factor for toenail onychomycosis and fungal foot infection. DM also increases the risk of patient developing secondary bacterial infection if fungal infection goes unrecognized and untreated. Objective: To assess the prevalence and risk factors of toenail onychomycosis and fungal foot infection in Thai diabetic patients. Material and Method: This single center cross-sectional observational study recruited type 1 and type 2 diabetic patients older than 18 years who attended Siriraj Hospital between October 1, 2012 and November 30, 2013. Patient demographic data, clinical data, and medical history were collected by questionnaire and assessed. Diagnosis of fungal infection was confirmed by potassium hydroxide investigation and fungal culture was performed to identify the type of organism. Results: One hundred forty four diabetes outpatients were enrolled and 38.9% were men. The mean (±SD) age was 59.6±12.7 years. Fungal infection was diagnosed 46 cases (31.9%). There were 28 cases (61%) with only toenail onychomycosis, two cases (4%) with only fungal foot infection, and 16 cases (35%) with co-infection (fungal foot infection and toenail onychomychosis). The organisms identified as causing fungal foot infection and toenail onychomycosis were dermatophytes (44.4% and 34.1%, respectively), non-dermatophytes (44.5% and 47.7%, respectively), and Candida species (5.6% and 4.5%, respectively). Risk factors found to be significantly correlated with toenail onychomycosis and fungal foot infection were male gender (p = 0.001), age older than 60 years (p = 0.006), agriculture-related activities (p = 0.006), family history of dermatophytosis (p = 0.034), and co-morbidity coronary heart disease (p = 0.044). No significant association was found for BMI, duration of DM, HbA1c, and diabetes related complications. Conclusion: Prevalence of fungal foot and toenail infection in Thai diabetes patient was 31.9%. We found higher prevalence of non-dermatophyte organisms as the cause of dermatomycosis and toenail onychomycosis. Accordingly, clinical diagnosis without proper culture identification may result in treatment failure.

Epidemiology, Clinical Characteristics, Sites of Infection and Treatment Outcomes of Mucocutaneous Candidiasis Caused by Non-Albicans Species of Candida at a Dermatologic Clinic.

BACKGROUND: Increasing numbers of mucocutaneous infection due to non-albicans species of Candida (N-CA) had been reported. Laboratory based studies showed multidrug resistance in N-CA population. OBJECTIVE: Demonstrate epidemiology, clinical characteristics, sites of infection, and treatment outcomes of mucocutaneous candidiasis caused by N-CA at a dermatologic clinic, including statistical evaluation data between N-CA and C. albicans infections. MATERIAL AND METHOD: This was a cross sectional study of outpatients with mucocutaneous infection due to Candida at Dermatologic clinic between January 2012 and June 2014. Vaginal candidiasis was excluded. Demographic, clinical, laboratory data, and treatment outcomes were collected. RESULTS: Among 760 patients presented with mucocutaneous candidiasis, 307 (40.4%) were infected with N-CA. The mean age (SD) of N-CA patients was 63.6 (10.4) years and 74.6% were female. The majority of N-CA cases were isolated from patients' nails (n = 293, 95.4%) while eight (2.6%) were detected from their skin, and six (2%)from oral mucosa. Comparison between N-CA and C. albicans, skin, and mucosa infection were significantly demonstrated in C. albicans groups (p < 0.001). Among nail infected patients, C. albicans infections had significant higher severity than the N-CA infection (p = 0.017). Median time to cure in N-CA population was 169 days, which had no significant difference from C. albicans groups (211 days, p = 0.499). CONCLUSION: Forty percent of mucocutaneous candidiasis was caused by N-CA. Nails were the most common sites of N-CA infections but N-CA was sometime found in skin and mucosa. Treatment outcomes of N-CA population were not significantly different from those of C. albicans groups.

Efficacy and Safety in 1% Clotrimazole Powder, Adjuvant Therapy in Patients with Superficial Fungal Cutaneous Infection in Intertriginous Areas.

Background: Superficial fungal cutaneous infection is commonly found in intertriginous area. Objective: To assess 1% clotrimazole powder (1% CP) efficacy for adjuvant treatment of superficial fungal cutaneous infection in intertriginous areas. Material and Method: The study performed as an open-label, randomized, comparative study for evaluating the effects of 1% clotrimazole cream (1% CC) with 1% CP in patients infected with dermatophytes (DMPs) or Candida spp. in intertriginous area, comparing to patients treated with 1% CC as control by demonstrating complete cure rate at 4, 8, and 12 weeks as well as relapse rates during a 24-week period including patient satisfaction. Results: Sixty-seven patients with mean age of 54.6 years were included in this study. Of those, 61.2% were males. Thirty-five patients were infected with DMPs and 32 with Candida spp. The complete cure rates of experimental group were significantly higher than the control group, as observed within four weeks (p = 0.01), especially for dermatophyte infection (p = 0.039). Two cases had recurrent candidiasis in the control group. In both groups, relapse up to 24 weeks were not statistically different. Additionally, there was no difference in patients' satisfaction towards convenience of drug application. Conclusion: Using of the 1% CP could be suggested as an adjuvant therapy and possibly preventive agent for superficial fungal cutaneous infection in intertriginous areas.

Randomized controlled trial and cost-effectiveness analysis: Comparing chlorhexidine scrub, ZnO-nanoparticle socks, and their combination in pitted keratolysis treatment.

A cost-effective treatment for pitted keratolysis (PK) is the use of 4% chlorhexidine scrub. Zinc oxide nanoparticle (ZnO-NP)-coated socks have also shown efficacy in PK prevention. In this study, we aimed to assess the cost-effectiveness and safety of combined 4% chlorhexidine scrub and ZnO-NP-coated sock treatment compared to monotherapy. This randomized, controlled trial included 60 male security guards and hospital porters aged ≥18 with PK. Participants were randomly assigned to one of three treatment groups: 4% chlorhexidine scrub, ZnO-NP-coated socks, or combination therapy. Treatment outcomes were evaluated after 4 weeks. Incremental cost-effectiveness ratios (ICERs) were calculated using cost-utility analysis. The greatest reduction in visual analog scale scores for foot odor was observed in the combination therapy group, but it was nonsignificant (P = 0.186). Clinical improvement was observed across all groups. The cost-utility analysis revealed that chlorhexidine scrub and regular socks were the least expensive options. The placebo and ZnO-NP-coated sock group had an ICER of US $31 082/quality-adjusted life years (QALYs) gain, while the combination therapy gained US $45 105/QALYs compared to the chlorhexidine scrub and regular sock group. Based on our findings, for the treatment of PK, 4% chlorhexidine scrub remains the most cost-effective choice.

In Vitro Antifungal Activity of Plain Socks and Zinc Oxide Nanoparticle-Coated Socks.

BACKGROUND: Fungal foot infection is a common superficial fungal infection and is recognized as an important public health problem. Related to the wearing of occlusive footwear, foot infection is usually caused by dermatophytes and nondermatophyte molds. Previous in vitro studies have demonstrated that zinc oxide nanoparticles (ZnO-NPs) have antimicrobial activity against fungi. This study, therefore, evaluated the ability of socks coated with ZnO-NPs to inhibit fungal growth in an in vitro model mimicking real-life situations. METHODS: Scale from patients with fungal foot infections was equally divided into three groups: control, plain socks, and ZnO-NP socks. The specimens in the control group were routinely fungal cultured, whereas in the plain sock and ZnO-NP sock groups, scale was incubated with plain socks and ZnO-NP socks, respectively, for 24 hours. After incubation, each piece of sock was cultured. The fungal culture results of the three groups were progressively evaluated for 4 weeks. RESULTS: From 31 specimens, the positive fungal culture results of the control, plain sock, and ZnO-NP sock groups were 100%, 64.5%, and 54.8%, respectively. Specimens incubated with plain socks (P = .001) or with ZnO-NP socks (P < .001) had a significant reduction in the number of positive fungal cultures compared with the control. CONCLUSIONS: Plain socks and ZnO-NP socks significantly inhibited fungal growth relative to the control. The wearing of either plain socks or ZnO-NP socks can prevent fungal foot infection because these socks act as a barrier to the insoles of shoes.

Efficacy of a Newly Developed Inward Airflow Safety Cabinet to Prevent the Spread of Infected Nail Dust Particles During Mechanical Nail Reduction in Onychomycosis.

BACKGROUND: Nail thickening is a poor prognostic factor in onychomycosis. Mechanical reduction by micromotor nail grinding is an alternative treatment for onychomycosis. However, this treatment introduces a large amount of infected nail dust particles into the air and can adversely affect other patients and health-care providers. The innovative recirculating airflow safety cabinet (ASC) was developed to prevent the spread of these generated infected nail dust particles. The aim of this study was to determine the efficacy of the ASC in patients with onychomycosis or traumatic onychodystrophy. METHODS: The ASC was used during the nail-grinding process in 50 patients, including 36 onychomycosis patients and 14 traumatic onychodystrophy patients. For each patient, five Sabouraud dextrose agar plates with chloramphenicol were positioned within the working space of the ASC, and the other five plates were positioned near the area of air exit after the carbon filters within the cabinet. A total of 500 plates were incubated at 25°C and evaluated every 7 days. The results of fungal cultures were analyzed. RESULTS: In the traumatic onychodystrophy group, all fungal cultures of nail dust particles from both before and after filtration from the ASC were negative in all 14 patients. In the onychomycosis group, 52 fungal cultures (28.9%) from nail particles within the ASC working area tested positive; however, the results of fungal cultures of nail dust particles after filtration were all negative. CONCLUSIONS: The newly developed ASC was found to be effective for preventing the spread of infected nail dust particles generated by micromotor nail grinding to mechanically reduce nail thickness in patients with onychomycosis.

A randomized controlled trial to compare the effectiveness and safety of adsorbent lotion containing tapioca starch, spent grain wax, Butyrospermum parkii extract, argania spinosa kernel oil, aloe barbadensis, rosehip oil, and allantoin with a low-potency topical corticosteroid in the treatment of intertrigo.

BACKGROUND: Intertrigo is an inflammatory skin-fold condition. Candida infections may occur concurrently or afterward. Topical corticosteroids may reduce inflammation but exacerbate Candida infections. The treatment is contentious. OBJECTIVE: To evaluate the efficacies and safety of adsorbent lotion containing tapioca starch, spent grain wax, Butyrospermum parkii extract, argania spinosa kernel oil, aloe barbadensis, rosehip oil, and allantoin for the treatment of mild-to-moderate intertrigo, relative to 1% hydrocortisone cream. METHODS: This randomized, double-blinded study enrolled 40 intertrigo patients. Twice daily, 20 patients applied adsorbent lotion while the remainder used 1% hydrocortisone cream. Efficacy evaluation, skin biophysical measurements, skin tolerability, safety, and visual analog scale (VAS) patient-satisfaction scores were evaluated at baseline and Week 2. RESULTS: The adsorbent lotion showed higher complete cure rates for color, partial epidermal loss, papules/pustules/vesicles/patches, dryness, and scaling than the corticosteroid without statistical significance. Adsorbent lotion demonstrated significantly higher reduction in pruritus than the corticosteroid treatment. Reduction of erythema level using Mexameter and VAS patient-satisfaction scores were not statistically different between adsorbent lotion and hydrocortisone cream. No adverse effects or superimposed infections were reported. CONCLUSIONS: The anti-inflammatory efficacies of adsorbent lotion and low-potency steroid were equivalent. The lotion was safe and produced excellent pruritus reduction. Patient satisfaction was high.

The Use of Adhesive Tapes to Transfer Skin-scrapings for Sequential Laboratory Diagnosis of Dermatophytosis.

BACKGROUND: Dermatophytosis usually causes a skin problem, which requires both clinical findings and laboratory investigations for diagnosis. Whereas, fungal culture is considered as the gold standard procedure, it is more difficult to perform compared to potassium hydroxide（KOH）examination. OBJECTIVE: To evaluate the efficacy of KOH and fungal culture examinations from skin-scraping specimens, which were kept in transparent adhesive tapes at different time intervals. METHODS: Skin-scraping specimens were collected from clinically suspected cases by conventional technique using scalpel blades and kept using transparent adhesive tapes. KOH（10%）preparation and fungal cultures were then performed by highly experienced technicians at different time intervals: day 0（the day of specimen collection, which was set as the standard reference point）, day 3 or 4, day 7, day 14, and day 28. Thereafter, the yield for detection of fungal elements by KOH examination and positive fungal cultures from specimens stored in adhesive tape was determined at different time intervals and compared to the results from the standard reference point. RESULTS: The sensitivity of KOH exami-nations from 162 patients at different time intervals showed no significant difference when compared to the standard reference point at day 0. In contrast, the sensitivity of fungal culture progressively decreased as the storage period was prolonged. CONCLUSIONS: KOH examination of skin-scrapings from the adhesive tape storage technique yield good results even when specimens have been kept up to one month. On the other hand, the sensitivity of fungal cultures gradually declines as storage time is extended.

Efficacy of 5% amorolfine nail lacquer in Neoscytalidium dimidiatum onychomycosis.

BACKGROUND: Amorolfine nail lacquer was mentioned as an effective treatment for non-dermatophyte nail infection. Onychomycosis that caused by Neoscytalidium dimidiatum is considered recalcitrant onychomycosis. OBJECTIVE: This study aimed to demonstrate efficacy and treatment outcomes of amorolfine nail lacquer in N. dimidiatum onychomycosis, compared with topical urea treatment. METHODS: This was a retrospective study of patients daiagnosed as N. dimidiatum onychomycosis at dermatologic clinic between April 2010 and August 2014. Clinical manifestations and laboratory results were collected. The evaluation included 50% improvement, which meant 50% decrease in subungual hyperkeratosis thickness from original untreated nails. Mycological cure is defined by negative result of both KOH and fungal culture. Moreover, complete cure means infected nails return to its normal condition as well as KOH and fungal culture yield negative results. RESULTS: Among 53 outpatients of N. dimidiatum infection, 28 (52.8%) were treated by amorolfine nail lacquer and other 26 (47.2%) by conventional topical urea cream with occlusion. Comparison between amorolfine and topical urea groups, mycological cure rate was significantly shown in amorolfine group (89.3% vs. 32%; p < 0.0001). Moreover, 50% clinical improvement and complete cure rate of amorolfine group were significantly higher than those of topical urea group (85.7% vs. 48%; p = 0.003 and 50% vs. 20%; p = 0.023, respectively). Median time to mycological cure and complete cure in amorolfine group was significantly shorter than that of topical urea group (p = 0.001 and p = 0.013, respectively). CONCLUSION: This study supported that amorolfine nail lacquer provided promising efficacy in the treatment of Neoscytalidium onychomycosis as a novel monotherapy regimen which were superior to topical urea cream with occlusion in every aspect.

Skin scrapings versus standardized skin surface biopsy to detect Demodex mites in patients with facial erythema of uncertain cause - a comparative study.

BACKGROUND: Standardized skin surface biopsy (SSSB) is considered to be the gold standard technique to evaluate the density of Demodex mites for the diagnosis of demodicidosis. Potassium hydroxide (KOH) preparation of skin scrapings is a much simpler procedure that can be used to detect pathogens in the superficial skin. OBJECTIVE: To evaluate the reliability of potassium hydroxide preparation of skin scrapings as compared to the standard skin biopsy technique with regard to capacity to detect Demodex mites, time consumed and technician satisfaction. METHODS: One hundred outpatients presenting with facial erythema of uncertain cause were enrolled. Standardized skin surface biopsy and potassium hydroxide preparation of skin scrapings were undertaken in adjacent areas on the patients' right cheek. LIMITATION: Patients with normal facial skin were excluded from the study. RESULTS: The accuracy of Demodex mite detection by potassium hydroxide preparation of skin-scrapings when compared to the standard procedure is 82%. The sensitivity, specificity, positive and negative predictive values of this method are 75%, 84.2%, 60% and 91.43%, respectively. There was no statistically significant difference between the standard and skin scraping techniques (P = 0.238) with regard to mite detection. Mean preparation time while using the skin scraping technique was 6 times less than that of the standard technique. For interpretation also, skin scraping technique (3.6 min) consumed much less time than the biopsy technique (9.8 min). Moreover, experienced technicians were more satisfied with skin scraping. CONCLUSION: Potassium hydroxide preparation of skin scrapings is an effective, time saving and practical technique to detect Demodex mites with accuracy comparable to the standard biopsy method.

Distinct characteristics of Scytalidium dimidiatum and non-dermatophyte onychomycosis as compared with dermatophyte onychomycosis.

Studies of demographic data, predisposing factors and clinical manifestations of non-dermatophyte mold (NDM) infection particularly in Scytalidium spp. have been limited. This study aimed to compare these data between dermatophytes (DMP) and NDM onychomycosis with statistical analysis. This was a retrospective chart review of outpatients with onychomycosis in the Nail Clinic of Department of Dermatology between January 2011 and December 2013. A total of 237 patients who had presented with onychomycosis were included. One hundred and eighty patients (75.9%) were infected with DMP: Trichophyton mentagrophytes, 46.8%; and Trichophyton rubrum, 28.3%. Of patients who had NDM onychomycosis, 17.3% were Scytalidium dimidiatum and 6.8% were Fusarium spp. Comparing the DMP and NDM groups, family history of superficial fungal infection was significantly demonstrated in the DMP group. Approximately 50% of patients in both groups had feet infections. However, no patients with NDM onychomycosis had fungal glabrous skin infection at other sites beyond the feet that was statistically different from cases with DMP onychomycosis. In conclusion, The distinct characteristic of patients with NDM onychomycosis was absence of fungal glabrous skin infection in areas other than the feet. This was statistically different from DMP.

Tinea capitis caused by Trichophyton tonsurans presenting as an obscure patchy hair loss due to daily antifungal shampoo use.

Tinea capitis is unusual and often misdiagnosed in healthy adults. We report a case of a healthy woman with a several-year history of asymptomatic, bizarre-shaped, non-scarring alopecia. She had used over-the-counter ketoconazole shampoo regularly for a long time. An initial potassium hydroxide preparation showed negative result for fungal organism. The scalp biopsy revealed endothrix infection, and dermoscopic examination demonstrated the comma hair and corkscrew hair signs. The fungal culture showed Trichophyton tonsurans. The daily use of antifungal shampoo could be the important factor to conceal clinical and laboratory findings for diagnosis of T. tonsurans tinea capitis in our case, which required high clinical suspicion and histopathology and dermoscopic examinations.