A rationale for systemic treatment in onychomycosis with negative results on fungal examination.

BACKGROUND: Fungal infection of the nail affects millions of people worldwide, and has an estimated prevalence of about 10% of the general population. Laboratory confirmation of fungal infection is currently accepted as a requirement before initiation of antifungal treatment in clinical practice. AIM: To examine the rationale for systemic treatment in cases of clinical onychomycosis with negative results on fungal examination (potassium hydroxide test and fungal culture). METHODS: In total, 147 patients with suspected clinical toenail onychomycosis but with negative results on fungal examination underwent up to three consecutive fungal examinations of the affected nails. Patients who were negative after these examinations underwent a fourth set of investigations, including PCR. RESULTS: Of the 147 cases initially thought to be negative, 138 (94%) were rated as positive after up to four consecutive sets of laboratory mycological investigations including PCR. Trichophyton rubrum was by far the commonest dermatophyte cultured from all samples. CONCLUSIONS: In the majority of cases of initially negative examinations, consecutive laboratory fungal tests will eventually produce positive results. These findings suggest that systemic antifungal treatment should be started in patients with suspected fungal infections, even if they have negative laboratory fungal examinations.

A novel two-step kit for topical treatment of tinea pedis--an open study.

BACKGROUND: Tinea pedis is a common skin disease affecting most of the population during their lifetime. Topical and systemic treatments give only temporary relief. OBJECTIVE: To evaluate the efficacy and safety of a new topical treatment for moderate-to-severe tinea pedis. METHODS: Fifty patients suffering from tinea pedis were treated in two stages: the active stage--single use of the novel topical solution for 45 min and novel cream twice weekly for 4 weeks; the preventive stage--cream application once weekly for 10 months. RESULTS: Forty-five patients completed the active stage and achieved 76% cure rate. The medication was well tolerated; one patient dropped from the study because of very mild irritation. No other topical or systemic side effects were noted. Another five patients were lost to follow-up during the preventive stage. The total cure rate after the preventive stage was 70%. CONCLUSIONS: This novel treatment was found to be effective, well tolerated and safe in the treatment of moderate and severe tinea pedis during the active and the preventive stages.

New criteria for the laboratory diagnosis of nondermatophyte moulds in onychomycosis.

BACKGROUND: Nondermatophyte moulds (NDM) may be found as aetiological agents or as contaminants in onychomycosis. The classic and most used criteria for the diagnosis of NDM are those established by English in 1976. OBJECTIVES: The aim of this article is to re-evaluate the laboratory criteria for the diagnosis of NDM in onychomycosis. PATIENTS AND METHODS: Patients with suspected NDM of the nail underwent five consecutive examinations by both KOH and mycological culture; at the first visit, three samples from the affected nail were taken and were examined separately. Later those patients underwent four consecutive examinations; during this stage only a single sample for both KOH and culture was taken. We compared the culture results obtained from the three nail samples obtained at the first visit with the results from the four consecutive visits. RESULTS: We noted a clear trend showing that as the number of positive cultures increases (one to three cultures) during the first examination, the percentage of subsequent positive cultures, taken during the four consecutive visits, also increased. CONCLUSIONS: We suggest that when NDM infection is found in the first culture, the patient should be re-examined in a subsequent visit in which three separate samples are taken from the affected nail. If NDM is confirmed in all three cultures, the diagnosis of NDM is established. Treatment should be recommended in patients who show positive results in all three cultures.

A randomized, double-blind, placebo-controlled study to evaluate the efficacy in AD of liquid soap containing 12% ammonium lactate + 20% urea.

Atopic dermatitis (AD) is a common chronic skin disease, which mainly affects children. Xerosis is one of the most troublesome signs of the disease. The aim of this study was to evaluate the efficacy of liquid soap containing 12% ammonium lactate + 20% urea in patients with AD. In a randomized, double-blind study, 36 patients (both male and female patients; age range 3-40 years) with mild to moderate AD were enrolled. Patients were divided randomly into two groups, in a ratio of 2:1 (active:placebo). The prescribed soap was used on a daily basis during a shower for 3 weeks. All patients continued all other systemic or topical medication but avoided any other soap or emollients. After 3 weeks of treatment, efficacy was assessed both by clinician and patient. There were significant improvements in scaling (P < 0.0001), skin dryness (P < 0.0001) and redness (P = 0.03) as rated by the investigator, and subjective patient assessment of itch also improved (P < 0.001) in the study group compared with the control group. The liquid soap was found to be effective in patients with AD, as use of this soap in patients with stable mild to moderate AD improved the parameters studied.

Collection of fungi samples from nails: comparative study of curettage and drilling techniques.

BACKGROUND: Onychomycosis is a common problem. Obtaining a positive laboratory test before treatment is important in clinical practice because the treatment of onychomycosis requires expensive oral antifungal therapy with potentially serious side-effects. OBJECTIVE: The purpose of this study was to compare curettage and subungual drilling techniques of nail sampling in the diagnosis of onychomycosis. METHODS: We evaluated 194 patients suffering from distal and lateral subungual onychomycosis and lateral subungual onychomycosis using curettage and subungual drilling sampling techniques. Nail samples were obtained in each case from proximal, medial and distal parts of the nail. KOH examination and fungal culture were used for detection and identification of fungal infection. RESULTS: With each technique, the culture sensitivity improved as the location of the sample was more proximal (drilling proximal vs. distal, chi(2) = 5.15, P = 0.023; curettage proximal vs. distal, chi(2) = 4.2, P = 0.041). In each sample location, the drilling technique has a better culture sensitivity (drilling vs. curettage proximal, chi(2) = 11.9, P = 0.001; drill vs. curettage distal, chi(2) = 13.7, P < 0.0001). Trichophyton rubrum was by far the most common pathogen detected by both techniques from all sampling sites. CONCLUSION: The drilling technique was found to be statistically better than curettage at each site of sampling. With each technique, we found that the culture sensitivity improved as the location of the sample was more proximal. More types of pathogens were detected in samples taken by both methods from proximal parts of the affected nails.

Onycomycosis due to artificial nails.

BACKGROUND: The use of artificial nails (ANs) as part of nail-care cosmetics is very popular. Several side effects and complications, such as contact dermatitis and bacterial and fungal infections, have been reported in patients using ANs. Objective The purpose of this study was to identify the fungal pathogens in nail abnormalities appearing in patients with ANs. METHODS: We evaluated 68 patients suffering from nail changes and paronychia, which appear after removal of ANs. Mycological samples were obtained from two sites: distal parts of the involved nail and the proximal nail fold. KOH examination and fungal culture were used for detection and identification of fungal infection. RESULTS: Mycological results from the distal part of the nail showed positive KOH test in 57 cases (83.8%), and culture was positive in 67 patients (98.5%). Mycological results obtained from the proximal nail fold showed positive KOH test in 36 patients (52.9%); in 36 of the cases, culture was positive. Candida spp. were the most common pathogen. Both KOH and culture results were significantly better while sampling from the distal part of the nail compared with sampling from the proximal nail fold (P = 0.0001). CONCLUSION: Onychomycosis was found to be very common in nail changes due to ANs, leading to an increased risk of transmitting microbial infections. Therefore, health care personnel and workers in the food industry should avoid using ANs.

Macrophage migration inhibition factor (MIF) in drug eruption.

A controlled study was conducted to evaluate the macrophage migration inhibition factor test as a diagnostic aid in 50 patients with drug eruption. Two groups of patients served as controls: group A, 110 patients being treated with drugs without known cutaneous adverse reactions, and group B, 15 patients suffering from dermatologic disorders unrelated to drugs being taken. Positive macrophage migration inhibition factor responses were found toward a variety of drugs in 35 (70%) of the patients with drug eruptions, with no relation to the type of eruption or the duration of drug intake. The percentage of positive macrophage migration inhibition factor responses toward drugs in the patients with drug eruptions was higher than that in the two control groups (4.5% and 6.7%, respectively). The percentage of positive macrophage migration inhibition factor responses recorded for clinically "suspected" drugs was significantly higher than that recorded for the "nonsuspected" drugs.

Dapsone - the treatment of infectious and inflammatory diseases in dermatology.

Dapsone is known as useful in the treatment of infectious diseases. The use of the drug in infectious and inflammatory diseases in dermatology is reviewed.

Griseofulvin and its uses.

Griseofulvin has been used in the treatment of dermatophyte infections for the past 30 years. The use of the drug in treating other medical conditions is reviewed.

Transition between solar keratosis and basal cell carcinoma.

Transition from solar keratosis (SK) to squamous cell carcinoma (SCC) is well known and vastly documented. The possible relation between SK and basal cell carcinoma (BCC) is rarely mentioned in the dermatopathological literature. In order to identify the characteristics of the relation between SK and BCC, 40 slides of the head and neck regions in which both SK and BCC had been diagnosed, were retrieved from a collection in the Institute of Pathology of Beilinson Medical Center, seen between 1984 and 1994. Gradual and continuous transition between SK and BCC was found in 15 (37.5%) of these 40 slides. In order to estimate the prevalence of this phenomenon, 73 additional slides, which had been diagnosed as BCC of the head and neck, were re-examined. Atypia of the spinous layer, as an initial marker for the development of SK, was sought in each slide. Revision revealed spinous layer atypia in 26 (35.6%) slides, in addition to the previously diagnosed BCC. In seven (9.6%) the transition between atypical spinous cells and BCC was gradual and continuous. A gradual and continuous transition between SK and BCC can be explained by the presence of pluripotent stem cells in the epidermis. Stem cells, following malignant transformation, may differentiate in different directions, resulting in both SK and BCC.

Allergic vasculitis induced by Decapeptyl: confirmation by macrophage migration inhibition factor (MIF) test.

A case of allergic vasculitis of the skin following treatment with Decapeptyl (D-Trp6-LHRH) for in vitro fertilization is described. The possible role of an allergic mechanism in this reaction has been suggested by a positive macrophage migration inhibition factor (MIF) test toward the drug.

Localized hypopigmented mycosis fungoides in a 12-year-old caucasian boy.

Mycosis fungoides is uncommon during childhood. We describe a Caucasian child who presented a single hypopigmented lesion of mycosis fungoides.

A case of pemphigus vulgaris with esophageal involvement.

Esophageal involvement in pemphigus vulgaris is rare, found more in women than in men, and can be the only manifestation of pemphigus. Esophageal involvement had been reported only among patients with pemphigus vulgaris and not in patients with other forms of pemphigus. We describe a case of pemphigus vulgaris in which the esophagus was severely involved with only few oral lesions and no involvement of the skin or oropharynx.

Keratosis lichenoides chronica: a variant of lichen planus.

In order to establish a possible relationship between keratosis lichenoides chronica (KLC) and lichen planus (LP), we performed a comparative study which included routine histologic examination, electron microscopy, and direct immunohistochemical studies from one case of KLC and several patients with LP. Our findings demonstrate that KLC and LP share many similarities; their differences are mostly quantitative. In KLC, the findings are more prominent; we therefore conclude that KLC is at one end of the spectrum of LP.

Hypopigmented mycosis fungoides in a white female.

A rare case of a young Caucasian female with hypopigmented mycosis fungoides is described. We reviewed and discussed the literature.

In vitro analysis of bromine chemical burns with use of full-thickness human skin.

Parameters of bromine injury were studied in vitro with the use of full-thickness human skin (HS) specimens--discards from various surgical procedures. The morphology of in vitro-treated HS resembled that of in vivo-injured skin. The damage was pronounced in the epidermis (destruction of the stratum corneum, and extensive vacuolation of keratinocytes) and the dermis (collagen coagulation), depending on the bromine concentration, exposure time, and application method. A decreased viability of epidermal cells, assayed by dye exclusion, was observed as well. Permeation parameters of bromine via abdominal HS were determined by quantitating bromine concentration in the donor and receiving compartments. The amount of bromine that permeated HS was inversely related to the concentration gradient applied. This in vitro study suggests that prompt treatment and early medical intervention may be required for successful healing of both severe and mild cases of bromine injuries.

Specific cutaneous infiltrates in chronic myelogenous leukemia.

Specific leukemic infiltration of the skin is possible in all types of leukemia, and occurs most commonly in monocytic leukemias. We report the case of a 76-year-old woman with chronic myelogenous leukemia who showed specific cutaneous lesions one month before she died. In the absence of other signs of accelerated disease or blast crisis, cutaneous lesions should be considered an ominous sign in chronic myelogenous leukemia.

Subungual amelanotic melanoma.

We describe a 76-year-old white male with subungual amelanotic melanoma. The lack of pigmentation of the lesion may cause misdiagnosis and aggravate its poor prognosis.