No evidence of resistance to itraconazole in a prospective real-world trial of dermatomycosis in India.

BACKGROUND: The prevalence of superficial fungal infections in India is believed to have increased substantially in the past decade. We evaluated the treatment outcomes and risk factors associated with clinical response to a treatment course of itraconazole for the management of dermatomycosis in India. METHODS: In this real-world, prospective pilot study (August 2019 to March 2020), adult participants (18-60 years), diagnosed with T. cruris or T. corporis, received itraconazole 200 mg/day (any formulation) orally for 7 days, and were followed for an additional 7 days. RESULTS: The study was terminated early due to the COVID-19 pandemic. Of 40 enrolled participants (mean [SD] age, 35.5 [12.73] years; {62.5%}] male; 37 received itraconazole and 20 (50%) completed the study. The median (range) Clinical Evaluation Tool Signs and Symptoms total score at baseline was 5.5 (2-10). Clinical response of "healed" or "markedly improved" based on the Investigator Global Evaluation Tool at day 7 (primary objective) was 42.9% (12/28; 95% CI: 24.53%, 61.19%). Itraconazole minimum inhibitory concentration for identified microorganisms, T. mentagrophytes species complex (91.7%) and T. rubrum (8.3%), was within the susceptibility range (0.015-0.25 mcg/mL). At day 14, 8/13 (61.5%) participants achieved a mycological response, 2/13 participants (15.4%) had a mycological failure and 90% showed a clinical response. CONCLUSION: COVID-19 pandemic affected patient recruitment and follow-up, so the findings call for a careful interpretation. Nevertheless, this real-world study reconfirmed the clinical efficacy and microbial susceptibility to itraconazole for the fungi causing dermatophytosis in India. TRIAL REGISTRATION: Trial registration number: Clinicaltrials.gov NCT03923010.

Trichophytic Majocchi granuloma mimicking Kaposi sarcoma.

A 68-year-old man presented with a one month history of painful blue-red papules and nodules on an erythematous base on the top of his feet, as well as dystrophic toenails. He had undergone renal transplantation six months previously for membranous glomerulonephritis, and was immunosuppressed with tacrolimus 3 g, mycophenolate mofetil 1500 mg and prednisolone 5 mg daily. His tacrolimus level was 29.8 ng/ml (expected level 6-8 ng/ml). Even though the cutaneous lesions strongly suggested Kaposi sarcoma, the histological examination revealed a dermal abscess in which hyphae and spores were seen with PAS staining. ELISA-PCR of the biopsy identified Trichophyton rubrum, which was also grown on culture of the biopsy tissue. The diagnosis of Majocchi granuloma secondary to excessive immunosuppression was made. Systemic treatment with terbinafine 250 mg per day and topical ciclopirox olamine completely cured the granulomatous skin lesions, and later the nails.

Pimecrolimus-induced tinea incognito.

A 6-year-old boy was brought to his primary care provider by his mother, who complained of a pruritic rash near his right eye. The eruption was described as a small, erythematous, slightly scaly plaque at the lateral margin of the right eyelid. The child was in good health and took no medications. The diagnosis of eczema was made; the patient was treated with pimecrolimus cream b.i.d. to the affected area. After 2-3 days of treatment, the itching and erythema completely resolved; however, a rough and scaly plaque persisted. After 1-2 weeks of treatment, the itching gradually returned, and the lesion began to increase in size. Multiple, similar lesions appeared several centimeters from the initially affected area. Pimecrolimus was discontinued; topical nystatin/triamcinolone ointment was prescribed. The eruption continued to spread, and the patient was referred to dermatology for further evaluation. The patient presented to the dermatology clinic with multiple annular, scaly papules and plaques with central clearing. Excoriations and mild inflammation were noted around all affected areas (Figure). A potassium hydroxide examination of the lesions revealed numerous hyphae. The nystatin/triamcinolone ointment was discontinued; oral griseofulvin was prescribed. The eruption improved dramatically after 3 weeks and eventually cleared completely after 5 weeks of treatment. Topical 2% ketoconazole cream was applied b.i.d. for the final 2 weeks of treatment.

Tacrolimus-induced tinea incognito.

Tacrolimus and pimecrolimus represent a new class of topical nonsteroidal medications currently used in the treatment of a variety of inflammatory skin lesions. We report the case of a patient in whom topical tacrolimus therapy resulted in widespread lesions of tinea incognito. This case shows that partial treatment of dermatophytosis with griseofulvin may obscure the diagnosis. It also suggests that topical tacrolimus appears capable of inducing widespread dermatophytosis. The clinical appearance in this case was similar to tinea incognito induced by a topical corticosteroid.

Tinea incognito due to Trichophytom rubrum after local steroid therapy.

The term "tinea incognito" refers to dermatophyte infections with clinical presentations that have been modified by the administration of corticosteroids. We describe a patient who had pustular inflammatory skin lesions due to Trichophyton rubrum after receiving treatment with potent topical corticosteroid creams.

Tiña incógnito simulando dermatitis oclusiva por corsé ortopédico / Tinea incognito mimiking occlusive dermatitis by corset use

El uso de corticoides tópicos puede alterar las características clínicas de cualquier dermatosis denominándose tiña incógnito a las dermatoficias modificadas por tratamiento esteroideo. Entre las complicaciones cutáneas asociadas al uso de corsés ortopédicos están la dermatitís de contacto a los materiales del corsé y las dermatitis irritativas producidas por la acción del material plástico junto con la oclusión y la humedad. Se presenta un caso de una joven de doce años de edad en tratamiento con corsé ortopédico orientado inicialmente como una dermatitis oclusiva y posteriormente como una tiña Incógnito siendo la histología determinante para el diagnóstico (AU)

[Universal dermatophytosis (tinea incognito) caused by Trichophyton rubrum]. / Universelle Dermatophytose (Tinea incognito) durch Trichophyton rubrum.

An 84-year-old male presented with a dermatophyte infection that had spread over nearly the entire body surface. The first signs had developed 48 years before. After treatment with galenic and corticosteroid preparations for diagnoses of "eczema" and "psoriasis", the lesions gradually extended over the body and to the nails. The cutaneous symptoms had worsened in recent year after the patient had started systemic cortisone treatment for bronchial asthma. He also developed diabetes mellitus, papulonodular lesions on the face and limbs, thinning of his hair and eyebrows and hyperkeratosis of the soles and palms.

Induction of tinea cruris by topical nitrogen mustard and by systemic chemotherapy.

The present report describes the rapid clinical appearance of superficial fungus infections after the initiation of topical nitrogen mustard treatment in one patient and a short course of systemic cytotoxic drugs in another.