Ali Rıza Gür

An open, randomized, comparative study of oral fluconazole, itraconazole and terbinafine therapy in onychomycosis

OBJECTIVE: In this open, randomized and comparative study, the safety and efficacy of systemic fluconazole, itraconazole and terbinafine was investigated in 50 patients with distal subungual toenail onychomycosis diagnosed clinically and mycologically. The patients with positive mycology and also the patients with positive microscopy and negative culture were investigated. METHODS: The treatment duration was 3 months, and the follow-up period was 6 months. Patients were randomly assigned: 16 patients received 150 mg fluconazole once weekly, 18 patients received 200 mg itraconazole twice daily with meals during the first week of each month, and 16 patients received 250 mg/day terbinafine during the treatment period. RESULTS: In a clinical evaluation, at the endpoint of the follow-up period, the clinical cure rates were 81.3% (13/16) in the terbinafine group, 77.8% (14/18) in the itraconazole group, and 37.5% (6/16) in the fluconazole group. The mycological cure rates were 75% (12/16), 61.1% (11/18) and 31.2% (5/16), respectively. The overall assessment rates were 62.5% (10/16), 61.1% (11/18) and 31.2% (5/16), respectively. Statistically significant intra-group reductions from baseline symptom severity values were seen at the endpoint of treatment and at the endpoint of the follow-up period for all three treatment groups in onycholysis, subungual hyperkeratosis, affected-area percentage score and total score parameters (p < 0.001). At the endpoint of the follow-up period, statistically significant differences between the treatment groups were seen in clinical, mycological and overall assessment (p < 0.05). However, while no statistically significant difference between the terbinafine and itraconazole groups was seen, there was a clinical and statistical difference between the other groups and the fluconazole group. Treatment was not stopped for side effects such as mild gastrointestinal and central nervous system symptoms. These effects were noted in four patients in the fluconazole group (25%), five patients in the itraconazole group (27.8%), and three patients in the terbinafine group (18.75%). The clinical laboratory data on all three drug groups did not show any statistically or clinically significant intra-group changes from baseline values at the endpoint (p > 0.05). CONCLUSION: This comparative study of systemic fluconazole, itraconazole and terbinafine showed that all three drugs were effective and safe in the treatment of onychomycosis. However, fluconazole, at these doses and treatment durations, was the least effective. With regard to cost-effectiveness, side effects and the cure rates, terbinafine could be the drug of choice in the short-term treatment of toenail onychomycosis.

Anhidrotic ectodermal dysplasia with eruptive vellus hair cysts

A 21‐year‐old white man complained of heat intolerance, absence of sweating, and papular lesions on the forehead. Facial features included a saddle nose, prominent supraorbital edge, and frontal bossing. The scalp hair was scanty, fine, and brittle. Eyelashes and eyebrows were also thin. Subungual hyperkeratosis and dystrophic changes were observed on the finger and toe nails. Hypodontic teeth were detected on oral examination. He was otherwise healthy. Biochemical and hematologic analyses were also normal. Cutaneous examination revealed smooth and dry skin. Multiple, 4–5 mm, brown–black, comedo‐like, soft papules were observed on the forehead ( Fig. 1 ). A biopsy specimen from a papule on the forehead revealed cystic structures lined by squamous epithelium and containing laminated keratinous material and scattered obliquely and transversely cut vellus hairs ( Fig. 2 ). Topical application of 0.1% tretinoin for 2 months produced no clinical improvement.

Follicular mucinosis responding to isotretinoin treatment

Follicular mucinosis is a rare disorder of unknown etiology characterized by accumulation of mucin in the sebaceous glands and outer root sheaths of the hair follicles. It is divided into a primary benign type and a secondary type mostly associated with lymphomas. No effective standard therapy for follicular mucinosis is available. We describe the case of a 21-year-old Caucasian male who had papules, nodules, and erythematous plaques on his left shoulder, left arm, and right scapular region. He was diagnosed as primary benign generalized follicular mucinosis, and treated with isotretinoin. Almost complete remission was achieved in 4 months.

Mycophenolate mofetil in extensive alopecia areata: No effect in seven patients

Alopecia areata (AA) is an unpredictable, usually patchy nonscarring hair loss condition. The course of AA is extremely variable; the most common type shows high spontaneous remission. The other form of the disease leads to total scalp and body hair loss [1–4]. Severe forms of AA are extensive and progress rapidly showing recurrent tendencies and often resistance to treatment. Mycophenolate mofetil (MMF) is an immunosuppressive drug recently added to the therapeutic armamentarium against autoimmune and inflammatory skin diseases [5]. The principal aim of this study was to determine the efficacy of MMF in extensive AA. In addition, the effect of treatment on the T cell subpopulation was monitored by immunophenotypic analysis. Patients and Methods Seven patients with extensive and chronic AA affecting more than 50% of the scalp were selected for treatment with MMF. The subjects were all men, ranging in age from 20 to 26 years (mean 21.70). Diagnoses were confirmed by clinical appearance (scalp and body hair loss and nail involvement) and histological features. Scalp hair loss was divided into 4 groups: S1 = !25% hair loss, S2 = 26– 50% hair loss, S3 = 51–75% hair loss and S4 = 76–99% hair loss. All the patients were in the S3 and S4 groups with no body hair loss and nail involvement in this study. The patients were not suffering from any autoimmune disease and had not used any topical and systemic medication for at least 8 weeks before the study. Subjects with renal and cardiovascular disease, hypertension or serious medical illness were excluded from this study. Each patient was photographed at baseline and during the 16th week. The study was approved by the local ethical committee, and an informed consent was obtained from the subjects. The demographic data, duration of AA, last episode of a disease, any prior treatment and results of therapy are shown in table 1. The patients were treated with 2 g (500 mg per capsule, Cell Cept, Roche, Turkey) MMF daily for 4 months. Blood pressure and pulse measurements were made daily, and blood tests were performed every 15 days, including erythrocyte sedimentation rate, cell counts, liver and renal function tests and electrolytes. The patients were evaluated whether they had any side effects at each examination. Cosmetically acceptable responders were defined as subjects with 50% vellus or terminal hair. Four-milimeter punch biopsies were obtained from the center of active lesions at baseline and at the

Focal epithelial hyperplasia treated with interferon alpha-2a

BACKGROUND Focal epithelial hyperplasia (FEH) is an uncommon benign oral condition that occurs mainly in young individuals of certain racial groups. METHODS A 21-year-old Caucasian man presented with FEH of the oral mucosa. The patient was treated with interferon alpha-2a three times a week for 14 weeks intramuscularly (a total of 162 million units). RESULTS At 2 months after the end of therapy, the papular lesions showed partial regression. CONCLUSION This treatment modality should be used in cases with diffuse focal epithelial hyperplasia.BACKGROUND: Focal epithelial hyperplasia (FEH) is an uncommon benign oral condition that occurs mainly in young individuals of certain racial groups. METHODS: A 21-year-old Caucasian man presented with FEH of the oral mucosa. The patient was treated with interferon alpha-2a three times a week for 14 weeks intramuscularly (a total of 162 million units). RESULTS: At 2 months after the end of therapy, the papular lesions showed partial regression. CONCLUSION: This treatment modality should be used in cases with diffuse focal epithelial hyperplasia.

Atrophoderma vermiculatum with Melkersson-Rosenthal Syndrome

Atrophoderma vermiculatum (AV) is a rare disorder characterized by the occurrence of pitted, atrophic and depressed scars in a reticular or honeycomb pattern [1–3]. The Melkersson-Rosenthal syndrome (MRS) is an uncommon condition of uncertain pathogenesis and cause. The classic triad of signs includes recurrent orofacial edema, recurrent facial nerve palsy and lingua plicata [4, 5]. In this report, we present a case of AV associated with MRS. A 22-year-old male presented with skin atrophy on the cheek, orofacial swelling, recurrent facial paralysis and lingua plicata. Skin atrophy had started at the age of 6. Ten years later, orofacial swelling and lingua plicata occurred. Examination showed marked, pitted, honeycomb pattern scarring of the cheeks (fig. 1). There was no involvement of the eyebrows or any scarring alopecia. Upper lip enlargement and lingua plicata were observed, too (fig. 2). During the examination, no facial palsy was detected, but the patient complained of facial paralysis attacks in the past. There were no other skin lesions. Nails and teeth were normal. Histopathologic examination of a punch biopsy which was taken from the left cheek revealed minor atrophic malformations (worm-eaten appearance) in the epidermis and dermis, follicular plugging, small sebaceous glands and incompletely formed hair follicles (fig. 3). There was mild to moderate chronic inflammatory infiltration especially around the pilosebaceous follicle. Microscopic findings from the involved lips showed small noncaseating granulomas with Langhans’ giant cells found scattered throughout the edematous dermis. There was no family history of AV and MRS. Full blood screening as well as liver and renal test results were normal. We could not detect any clinical and X-ray evidence of tuberculosis, sarcoidosis, Crohn disease or odontogenic infections. With this knowledge, we diagnosed AV associated with MRS. AV is a relatively rare, benign condition that usually begins in childhood and is characterized by symmetric reticular or honeycombed skin atrophy of the cheek. Most cases are sporadic, but autosomal dominant inheritance has been described [1–3]. The primary defects of AV appear to be an abnormal keratinization and follicular hyperkeratinization of the upper part of the hair follicle, both of which may obstruct the growing hair shaft to produce a chronic inflammatory infiltrate with scarring below that level; such an abnormal keratinization may be related to congenital follicular dystrophy in and around the pilosebaceous follicle [2, 3]. Most cases of documented AV begin before puberty, but some of them begin at puberty or in adulthood. In this case, skin atrophy started at the age of 6. AV usually presents as a skin disease, but some rare reports of associations with certain syndromes can be found in the literature, i.e. with Fig. 1. Marked, pitted, honeycomb pattern scarring of the cheeks.

Treatment with intralesional interferon alpha-2a of genital warts with human papillomavirus genotyping

A group of 17 men and 3 women with genital warts in which DNA/RNA phenotyping was performed were treated with intralesional interferon alpha-2a (1 MU/cm2) three times weekly for 3 weeks. Treatment was followed by a 16-week observation period. Interferon alpha-2a treatment resulted in a highly significant reduction in the mean size of the warts, which decreased from an initial size of 37 mm2 to 4–5 mm2 by week 16 (P < 0.05). The response appeared to depend on the human papillomavirus (HPV) genotype. Patients with types 6 or 11 showed good responses in 11 of the 12 cases. The response in HPV types 16 and 18 infection was poor in 4 of the 8 cases. During follow-up (mean 4 months) no recurrence was observed. Intralesional treatment showed minimal side-effects. We conclude that intralesional interferon alpha-2a is useful in the treatment of genital warts caused by HPV of types 6 and 11.