Clinical Isolate of a Multi-Antifungal-Resistant Trichophyton rubrum.

The multi-antifungal drug-resistant strain (NUBS21012) of Trichophyton rubrum was isolated from a patient with recurrent tinea corporis. The resistant strain encoded Phe at codon 393 instead of Leu (L393F) in the squalene epoxidase (SQLE) gene. The expression of genes encoding ATP-binding cassette transporter proteins increased in the strain compared to that of other strains. This result provides evidence that ATP-binding cassette transporter proteins are closely associated with azole resistance.

Trichophyton indotineae sp. nov.: A New Highly Terbinafine-Resistant Anthropophilic Dermatophyte Species.

In this report, we describe the first isolation of two highly terbinafine (TRF)-resistant Trichophyton interdigitale-like strains from a Nepali patient and an Indian patient with tinea corporis in Japan. These strains (designated NUBS19006 and NUBS19007) exhibited a TRF minimal inhibitory concentration (MIC) of > 32 mg/L and contained a missense mutation (Phe397Leu) in squalene epoxidase (SQLE) gene. The internal transcribed spacer (ITS) region sequences amplified from the isolates (NUBS19006 and NUBS19007) were 99.5% identical to Japanese isolates of T. interdigitale and T. interdigitale strain CBS 428.63. The homology of region sequences were also 97.6% identical to T. mentagrophytes strain CBS 318.56. Moreover, the ITS sequences amplified from the isolates were 100% identical to highly TRF-resistant strains of T. interdigitale, which were isolated in Delhi, India, and harbored mutations in SQLE. The urease test on Christensen's urease agar was positive for T. mentagrophytes and T. interdigitale after 7 days of incubation. On the other hand, the type strain of T. rubrum CBS 100081 T and highly TRF-resistant strains (NUBS19006 and NUBS19007) were negative on Christensen urease agar after 7 and 14 days of incubation. Moreover, NUBS19006 and NUBS19007 were also negative reaction on the hair perforation test. To avoid confusion in the taxonomy of the T. mentagrophytes/T. interdigitale complex, we suggest that the highly TRF-resistant Indian strains be considered a new species independent of T. interdigitale, according to clinical and mycological features.

In vitro Azole Susceptibility Testing of Japanese Isolates of Terbinafine-Resistant Trichophyton indotineae and Trichophyton rubrum.

Multi-antifungal-resistant strains of Trichophyton indotineae and Trichophyton rubrum have been isolated in Japan. In the present study, we examined the in vitro susceptibility of terbinafine (TRBF) -resistant isolates of T. indotineae and T. rubrum to efinaconazole (EFCZ) and luliconazole (LUCZ). In all isolates, the minimum inhibitory concentrations were ≥ 32 mg/l for TRBF, < 0.03 to 16 mg/l for itraconazole, < 0.03 to 16 mg/l for ravuconazole, < 0.03 to 0.5 mg/l for LUCZ, and < 0.03 to 4 mg/l for EFCZ. Of note, T. rubrum NUBS21012 and T. indotineae NUBS 19006T showed resistance to LUCZ and/or EFCZ unlike the other isolates.

Dermatophyte antigen kit: A useful diagnostic tool for onychomycosis.

A dermatophyte antigen kit (DQT) was released in Japan as an in vitro diagnostic tool to identify tinea unguium in June 2022. From July 2022 to February 2023, we examined 75 potassium hydroxide (KOH)-negative patients (male, n = 23; female, n = 52; mean ± SD age, 63.6 ± 13.9 years) and determined the accuracy in confirming the fungal element with ZoomBlue™ staining at 400× magnification. The DQT results were classified into three categories. DQT-positive onychomycosis was detected in 27 patients with tinea unguium and two with non-dermatophyte onychomycosis. Fungal cultures were positive in 14 (51.8%) patients (Trichophyton rubrum [n = 11], T. interdigitale [n = 1], Fusarium solani [n = 1], and Talaromyces muroii [n = 1]). DQT-negative onychomycosis included ten patients with cured tinea unguium and 3 with Candida onychomycosis. Twenty-three patients had DQT-negative mimics for onychomycosis (onychauxis [n = 11], traumatic onycholysis [n = 8], yellow nail syndrome [n = 5], pincer nail deformity [n = 3], brittle nail syndrome [n = 2], contact dermatitis [n = 2], lichen planus [n = 1] and psoriasis [n = 1]). Because sparse, atrophic and/or fragmented mycelia are invisible in direct microscopy with potassium hydroxide (KOH) at 100× magnification, DQT was beneficial for diagnosing onychomycosis.

Treating onychomycoses of the toenail: clinical efficacy of the sub-millisecond 1,064 nm Nd: YAG laser using a 5 mm spot diameter.

BACKGROUND: Onychomycosis is a relatively common fungal infection. Current treatments have limited applicability and low cure rates. Recently introduced laser therapy has shown to be a safe and effective treatment for onychomycosis. In this study, we evaluate a submillisecond Nd:YAG 1,064 nm laser for treating onychomycoses of the tonail. METHODS: Thirteen subjects (9 female, 4 male) with 37 affected toenails received 1 to 3 treatments 4 and/or 8 weeks apart with a sub-millisecond 1,064 nm Nd:YAG laser. Diagnosis of onychomycosis was confirmed with microscopy. Average follow-up time was 16 weeks post-final treatment. Photos were taken and degree of turbidity was determined using a turbidity scale (ranging from "0 = clear nail" to "10 = completely turbid nail") at each visit. Improvement in turbidity was determined by comparison of turbidity scores at baseline and 16-week follow-up on average. Efficacy was assessed by an overall improvement scale (0 to 4), which combined improvement in turbidity scores and microscopic examination. Overall improvement was classified as "4 = complete clearance" if the turbidity score indicated "0 = clear nail" accompanied by a negative microscopic result. No microscopic examination was performed unless the turbidity score showed "0 = clear nail." RESULTS: Treatments were well tolerated by all subjects and there were no adverse events. Of the 37 toenails treated, 30 (81%) had "moderate" to "complete" clearance average of 16 weeks post-final treatment. Nineteen toenails (51%) were completely clear and all tested negative for fungal infection on direct microscopic analysis. Seven (19%) toenails had significant clearance and four (11%) had moderate clearance. CONCLUSIONS: The preliminary results of this study show this treatment modality is safe and effective for the treatment of onychomycosis in the short term. Additional studies are needed to more fully assess the clinical and mycological benefits as well as optimize the treatment protocol and parameters.

Biophysical evaluation of fractional laser skin resurfacing with an Er:YSGG laser device in Japanese skin.

BACKGROUND: Ablative fractional laser skin resurfacing (FLSR) has recently been used for the amelioration of acne scars, and previous studies have shown clinical effectiveness. Despite its extensive use, few studies have focused on the associated changes in biophysical properties of the epidermis. Herein, we evaluate transepidermal water loss, sebum levels, skin hydration, and skin elasticity, following FLSR treatments with an Er:YSGG laser device (Pearl FractionalTM, Cutera Inc., Brisbane, CA), employing non-invasive measurements. METHODS: Five Japanese patients with facial acne scars underwent one FLSR session. Some acne scars appeared to become less obvious as a consequence of the treatment. All patients were aware of a feeling of skin tightness in treated areas. RESULTS: Objective measurements on the lower lateral angle of the eye and on the inner cheeks were evaluated at baseline and at 3 days, 1 week, and 4 weeks after FLSR. Transepidermal water loss showed a significant two-fold (100%) increase at day 3, but had returned to almost the baseline level at week 4 in both areas. Sebum secretion showed a 50% increase at day 3, but had returned to the baseline level after day 7. Skin hydration showed a significant decrease at day 3, but had returned to the baseline level by day 7, and showed significant improvement at the end of the study. Skin elasticity (R2) was still at baseline on day 3, but showed some improvement--an increase of at least 30%--at the end of the study. CONCLUSIONS: Based on our findings, we believe that FLSR should be performed no more than once a month to allow sufficient time for the damaged skin to recover its barrier function in most areas of the face.

Empiric antifungal therapy in patients with cutaneous and subcutaneous phaeohyphomycosis.

We encountered two cases of phaeohyphomycosis caused by Exophiala jeanselmei and E. oligosperma that were treated with fosravuconazole and terbinafine, respectively. Our cases were successfully treated with empiric therapy before the pathogen's species or antifungal sensitivity had been determined. We summarized 32 cases of cutaneous and subcutaneous phaeohyphomycosis caused by Exophiala species in Japan. The patients received antifungals, including itraconazole, terbinafine, voriconazole, and fosravuconazole, and the treatment success rates of these monotherapies were 77% (17/22), 67% (8/12), 100% (5/5), and 50% (1/2), respectively. Although the broad-spectrum azole antifungal itraconazole is the first choice for treatment, terbinafine at 125 mg/day might exert the same efficacy. Fosravuconazole is a novel broad-spectrum azole and a moderate inhibitor of Cyp3A4 that causes fewer drug interactions than itraconazole and voriconazole, indicating a promising drug for this disease.

Kerion Celsi Caused by Nannizzia gypsea in a Two-Year-Old Child Who Had Been Hospitalized Since Birth.

Nannizzia gypsea, previously known as Microsporum gypseum, is a geophilic dermatophyte that infects humans from the soil. We isolated N. gypsea from a two-year-old girl with kerion celsi. Because of her serious medical condition, she was admitted to the pediatric ward immediately after birth. We struggled to identify the route of infection, and eventually identified her grandmother's handmade belt, which covered the endotracheal-tube-holding device, as the infection source. To prevent indirect transmission of pathogenic microorganisms from outside the hospital environment, our hospital prohibited the bringing of belongings from outside.

Fosravuconazole to treat severe onychomycosis in the elderly.

Fosravuconazole is a novel oral antifungal drug developed in Japan and used to treat tinea unguium since 2018. Its excellent oral absorbability and systemic bioavailability has enabled short-duration therapy of 3 months. Furthermore, no concomitant drugs are contraindicated due to the presence of the mild inhibitor of cytochrome P450 enzyme which is responsible for polypharmacy adverse effects. Therefore, it can be safely administrated to elderly patients. Elderly patients (≥65 years old) with severe onychomycosis (≥50% nail involvement) were treated with oral fosravuconazole 100 mg once daily for 12 weeks. The rate of involvement improved from 86.6% to 28.1% (P < 0.01). The efficacy (i.e. percentage of those rated as "improved" and better) and cure rate was 83.8% (31/37) and 29.7% (11/37), respectively. Furthermore, when focusing on the thin nail group (<3 mm), the efficacy and cure rate was 88.2% (15/17) and 58.8% (10/17), respectively. Although the serum γ-glutamyltransferase levels increased in 21.6% (8/37), all patients recovered without any specific treatments.

Non-dermatophyte Mould Onychomycosis in Japan.

The incidence of non-dermatophyte mould onychomycosis has been increasing worldwide for the past several decades, but it is not well recognized in Japan. Recent molecular techniques and phylogenetic analyses contributed to the identification of uncommon and emerging species. We came across 13 (0.5%) cases of non-dermatophyte onychomycosis among a total of 2,591 onychomycosis cases in 106,703 outpatients during the past 5 years (January 2015-December 2019). The cases included 5 patients with Aspergillus species, 4 patients with Fusarium species, and one patient each with Scopulariopsis brevicaulis and Botryosphaeria dothidea, respectively. Botryosphaeria dothidea is closely related phylogenetically to Neoscytalidium dimidiatum. In Japan, at the time of writing this report, there are 26 reported cases of ungual aspergillosis and 18 cases of hyalohyphomycosis caused by Fusarium species. We summarize these cases and report the symptoms and mycological features.

Ungual hyalohyphomycosis caused by Fusarium cugenangense.

Fusarium onychomycosis is uncommon in the temperate climate zone of Japan. Based on the morphological characteristics and a gene analysis, we diagnosed a patient with ungual hyalohyphomycosis caused by Fusarium cugenangense belonging to the F oxysporum complex. This intractable disease was cured by 6-month treatment with efinaconazole 10% solution.

Cutaneous Cryptococcosis

Cutaneous cryptococcosis is classified either as primary or secondary based on the route of infection. The disease can also be classified either as localized cutaneous cryptococcosis or cutaneous manifestations of disseminated cryptococcosis. However, from a physician's point of view, whether lesions are localized to the skin or are disseminated/systemic is more important than the route of infection. The Clinical Practice Guidelines for Diagnosis and Treatment of Cryptococcosis, which was established in 2019 by the Japanese Society for Medical Mycology, adopted the latter classification. Localized cutaneous cryptococcosis is defined as a condition in which lesions are confined within a limited part of the skin, not systemically disseminated at the same time, and are associated with neither cryptococcal fungemia nor antigenemia. This type of cutaneous cryptococcosis is uncommon in Japan. Only 65 cases were reported during the 50-year study period from 1968 to August 2018, with the patients divided into two groups: immunocompromised patients (n=44, 68%) and immunocompetent patients (n=21, 32%). None of the patients were infected with the human immunodeficiency virus (HIV). Localized cutaneous cryptococcosis can also occur in non-HIV-infected patients and well-appearing individuals, therefore, it is considered an important infection in routine dermatology practice. Here, we outline the classification, diagnosis, and treatment of cutaneous cryptococcosis and present a summary of cutaneous cryptococcosis cases reported in Japan.

Fungal melanonychia caused by Candida parapsilosis successfully treated with oral fosravuconazole.

A 73-year-old healthy woman noticed black pigmentation on both thumbnails for 6 years. Upon her visit to our clinic, she had pigmented onychomycosis with onycholysis in the distal area. There was no evidence of paronychia. Direct microscopy using Zoomblue™ and histopathological examination showed aggregated blastoconidia. Fontana-Masson staining confirmed fungal melanin production. A combination of morphological features and genetic testing identified the isolates as Candida parapsilosis. Fungal melanonychia due to C. parapsilosis is rare, with only six cases reported since 1979. The minimum inhibitory concentration of the isolates was 0.25 µg/mL for itraconazole, less than 0.03 µg/mL for ravuconazole and 2.0 µg/mL for terbinafine. Both oral terbinafine treatment and itraconazole pulse therapy performed for 6 months were unsuccessful. The disease was ultimately cured with a 3-month treatment of oral fosravuconazole.

Relationship between the Degrees of Itch and Serum Lipocalin-2 Levels in Patients with Psoriasis.

BACKGROUND: Lipocalin-2 (LCN2), a protein secreted mainly by activated neutrophils, has been associated with neurodegeneration, obesity, and inflammatory responses. Serum LCN2 concentration has been reported elevated in patients with psoriasis, but lower in patients with atopic dermatitis (AD). Spinal astrocyte-derived LCN2 was found to be involved in enhancement of itch in a mouse model of AD. However, the relationship between LCN2 and itch in patients with psoriasis has not been determined. Objective. This study examined the correlation between serum LCN2 levels and the degrees of itch in patients with psoriasis. METHODS: Serum LCN2 concentrations were measured by enzyme-linked immunosorbent assays (ELISA) in patients with psoriasis and AD and in healthy controls. The degree of itch was assessed using a visual analog scale (VAS), and disease severity was determined by measuring psoriasis area and severity index (PASI) and scoring atopic dermatitis (SCORAD). Correlations among serum LCN2 level, VAS, PASI, and SCORAD were analyzed statistically. We further examined the serum LCN levels in psoriasis patients before and after biological treatment. RESULTS: Serum LCN2 concentrations were significantly higher in patients with psoriasis and AD than those in healthy controls. In patients with psoriasis, serum LCN2 concentrations were significantly correlated with VAS, but not with PASI. In contrast, serum LCN2 concentrations did not correlate with VAS or SCORAD in patients with AD. Serum LCN2 levels in psoriasis patients significantly decreased after the biological treatment along with improvement of VAS. CONCLUSION: Serum LCN2 concentration is associated with the degree of itch in patients with psoriasis, suggesting that serum LCN2 may be a useful clinical marker for itch in psoriasis.

[Laser Therapies for Onychomycosis in Japan].

Various treatment methods other than oral and topical antifungal medications have been employed to treat onychomycosis. Treatment methods include mechanical removal of the affected part of the nail plate by using a toenail cutter or grinder and chemical removal by using occlusive dressing therapy with salicylic acid plaster or urea cream. In recent years, laser therapies have received attention as modalities for treatment of onychomycosis. Favorable outcomes in patients with onychomycosis have been reported in Japan from treatment combining carbon dioxide laser and topical antifungal drug, treatment with photodynamic therapy, and treatment with Nd:YAG laser. However, irradiation conditions, number of irradiation sessions, and efficacy evaluation methods vary among institutions and studies; thus, there is no established evidence to support these outcomes. In addition, a study reported that a combination of Nd:YAG laser and external antifungal drugs was more effective than each of the treatments alone. Future studies are required to provide clinical evidence on the effectiveness of laser therapies, on the enhancement of effect from the combination of laser and external antifungal drugs, and on the possibility of shortening treatment duration using laser therapies in the management of patients with onychomycosis.