C. Stinchi

Treatment of dermatophyte nail infections: An open randomized study comparing intermittent terbinafine therapy with continuous terbinafine treatment and intermittent itraconazole therapy

BACKGROUND terbinafine persists in the nail at effective concentrations for several weeks after discontinuation of treatment. OBJECTIVE Our purpose was to verify whether intermittent terbinafine therapy is effective in dermatophytic onychomycosis and to compare the results of intermittent terbinafine with those of intermittent itraconazole and continuous terbinafine treatment. METHODS An open, randomized study of 63 patients was performed with three treatment regimens: terbinafine, 250 mg daily (21 patients); terbinafine, 500 mg daily for 1 week every month (21 patients); or itraconazole, 400 mg daily for 1 week every month (21 patients). Treatment was continued for 4 months in toenail infections (60 patients) and 2 months in fingernail infections (3 patients). RESULTS At the end of the follow-up period (6 months after discontinuation of treatment) 16 of the 17 patients (94.1%) with toenail onychomycosis were mycologically cured in the terbinafine 250 mg group, 16 of 20 (80%) in the terbinafine 500 mg group, and 15 of 20 (75%) in the itraconazole group. CONCLUSION The percentage of patients who were mycologically cured was higher in the continuous terbinafine group than in the intermittent terbinafine and itraconazole groups, but statistical analysis did not reveal any significant difference between these cure rates.

Relapses of Onychomycosis after Successful Treatment with Systemic Antifungals: A Three-Year Follow-Up

Background: Data about relapses of onychomycosis after treatment with the new systemic antifungals vary among the different studies, with figures ranging from 3 to 20% for terbinafine and from 21 to 27% for itraconazole, depending on the follow-up duration. Objective: To determine the prevalence of relapses of onychomycosis cured by terbinafine compared with that of onychomycosis cured by itraconazole. Methods: We followed up 47 patients whose toenail onychomycosis had been mycologically cured in an open randomized study comparing intermittent itraconazole treatment with continuous terbinafine treatment and intermittent terbinafine therapy. Patients were examined every 3 months for up to 3 years after the end of therapy. At each visit clinical and mycologic (direct microscopy and cultures) evaluations were performed. Results: Eight of the 36 patients (22.2%) who completed the study had a relapse of onychomycosis during the follow-up period, including 2 patients of the terbinafine 250 mg group, 2 patients of the terbinafine 500 mg group and 4 patients in the itraconazole 400 mg group. As the original infection, the relapse was caused in all cases by Trichophyton rubrum. Conclusions: This study shows that 22.2% of patients with onychomycosis successfully treated with systemic antifungals experienced a relapse. The relapse rate increased from 8.3% at month 12 to 19.4% at month 24 and to 22.2% at month 36. Relapses were more common in patients treated with pulse itraconazole (4/11) than in patients treated with continuous (2/12) or intermittent (2/13) terbinafine. Statistical analysis did not reveal any significant difference between relapse rates in the three groups.

Onychomycosis due to Scopulariopsis brevicaulis: clinical features and response to systemic antifungals

Summary Six cases of Scopulariopsis onychomycosis, including four patients with onychomycosis exclusively caused by Scopulariopsis brevicaulis and two patients with a mixed nail infection (S. brevicaulis + Tricophyton rubrum and S. brevicaulis + T. interdigitale), are reported. Four patients presented with a typical distal subungual onychomycosis characterized by subungual hyperkeratosis and onycholysis of the distal nail plate. In two patients. Scopulariopsis infection produced a total dystrophic onychomycosis associated with painful periungual inflammation. Three patients were treated with four pulses of itraconazole. 400 mg daily for 1 week a month, and three patients with terbinafine, 250 mg daily for 4 months. The mycological examination 8 months after discontinuation of treatment showed that one patient was mycologically cured whereas the remaining five patients still carried S. brevicaulis in their nails. The clinical examination at the end of the follow‐up period showed a complete cure of the nail abnormalities in only one patient.

Proximal subungual onychomycosis due to Microsporum canis

Summary A case of proximal subungual onychomycosis due to Microsporum canis in a 36‐year‐old woman is presented. The onychomycosis involved the left thumb and the little fingernails, with thinning of the nail plate and crumbling of the nail plate surface. A milky‐white discoloration of the proximal portion of the left thumbnail was also evident. A 2‐mm longitudinal nail biopsy showed a large number of fungal elements in the whole length of the nail plate. Fungal hyphae were more numerous in the ventral nail plate and produced detachment of the superficial nail plate. The nail bed was not invaded by fungal elements and was devoid of inflammatory changes. Proximal subungual onychomycosis is uncommon in immunocompetent individuals but has frequently been described in patients with AIDS. In our patient, in whom the proximal subungual onychomycosis was due to M. canis, there were no clinical or biochemical signs of immunodeficiency. Oral treatment with terbinafine, 250 mg/daily for 2 months, produced clinical and mycological cure.

Retronychia in children, adolescents, and young adults: A case series

Turkey, and New Zealand reported an overall survival rate of 56% (25 of 45 patients). Eighty-three percent ofHI neonates treatedwith systemic retinoids survived, whereas the long-term survival was only 24% for those who were not given oral retinoids. Here we report the outcomes for HI in the Japan population. For a clinical survey of HI in Japan, we distributed questionnaires to 904 dermatologic or pediatrics institutes or hospitals throughout Japan in 2010 and received responses from 564 institutes or hospitals (62.4%). Clinical data between 2005 and 2010 were obtained for 16 HI patients. In total, there were 13 survivors (81.3%) and 3 deceased (18.7%). The patient’s sex was reported for 14 patients: 8 male and 6 female. Systemic retinoids were administered to 12 patients, 11 of whom survived (91.7%), whereas only 2 of the 4 patients (50%) who did not receive oral retinoids survived. Ten of 16 patients (62.5%) received intensive care in a neonatal intensive care unit (NICU). Systemic retinoids and administration in the NICU were considered to contribute to relatively good outcomes for HI patients in the Japanese population. The effects of oral retinoids in HI remains unproven, and as suggested in the commentary by Milstone and Choate, the early introduction of overall intensive therapy might have contributed to the better outcomes of the HI babies whowere given oral retinoids. In conclusion, we consider that, due to intensive neonatal care and, probably, to the early introduction of oral retinoids, HI outcomes have improved also in the Japanese population. In long-term HI survivors, epidermal keratinocytes might regain normal differentiation, and this restoration of differentiation is likely to be associated with the improvement of the skin symptoms in HI survivors. From this fact and the results of our clinical survey, we agree with the commentary by Milstone and Choate on the point that recognition of spontaneous improvement of the HI phenotype lowers the psychological hurdle and provides justification for intensive neonatal care that can improve the outcomes of HI patients. Akitaka Shibata, MD, Yasushi Ogawa, MD, PhD, Kazumitsu Sugiura, MD, PhD, Yoshinao Muro, MD, PhD, Riichiro Abe, MD, PhD, Tamio Suzuki, MD, PhD, and Masashi Akiyama, MD, PhD Department of Dermatology, Nagoya University Graduate School of Medicine; Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo; Department of Dermatology, Yamagata University Faculty of Medicine, Yamagata, Japan

SUBUNGUAL EXOSTOSIS OF A FINGER RESEMBLING PTERYGIUM INVERSUM UNGUIS

Nail Bone tumors X-ray Antonella Tosti, Istituto di Clinica Dermatologica, Università di Bologna, via Massarenti 1, I-40138 Bologna (Italy) Subungual exostoses are the most common benign bony proliferations associated with nail abnormalities. We report a case of subungual exostosis of the finger with atypical clinical appearance resembling a pterygium inversum unguis. Fig. 1. The lateral portion of the hyponychium is anchored to the under surface of the nail plate. Fig. 2. An x-ray showing the presence of an exostosis on the dorsal tip of the terminal phalanx.

Facial contact dermatitis due to spironolactone in an anti-acne cream.

Topical spironolactone has recently been introduced in Italy for the treatment of acne, on account of its antiandrogenic effects. Spironolactone is an aldosterone antagonist widely used systemically for disorders such as essential hypertension, primary hyperaldosteronism and edema associated with congestive heart failure or ascites of hepatic cirrhosis (1). Oral administration of spironolactone is frequently responsible for side-effects that are mostly due to its anti-androgenic action. Metabolic, neurologic and gastrointestinal side-effects have also been reported. Cutaneous manifestations account for a minority of side-effects (2): macular, papular or urticarial rashes (2), chloasma (3), erythema annulare centrifugum (4), annular lupus erythematosus (5), lupus-erythematosus-like (6) and lichen-planus-like eruptions (7). In dermatologic therapy, systemic spironolactone has been successfully prescribed in patients affected by androgen-related disorders such as acne vulgaris, hirsutism and androgenic alopecia (8). In spite of the effectiveness of systemic spironolactone in these cutaneous disorders, the anti-androgenic effects of the drug have limited its use to female patients. In order to avoid systemic adverse reactions, topical spironolactone has been proposed as a new therapeutic approach for both men and women.

Chronic atrophic erosive dermatosis of the scalp and atypical fibroxanthoma: a rare association

ejd.2012.1767 Auteur(s) : Francesco Savoia1,2 francesco.savoia@ausl.ra.it, Caterina Stinchi1, Lorenzo Valenti1, Laura Baldassari1, Giuseppe Gaddoni1, Federica Giacomini2, Annalisa Patrizi2, Loredana Cardinale3, Silvia Zago3 1 Unit of Dermatology, 2 Department of Internal Medicine Division of Dermatology, University of Bologna, Italy 3 Unit of Pathologic Anatomy, AUSL Ravenna, viale Dante 10, 48022 Lugo, Ravenna, Italy A 77-year-old Caucasian man, with a 10-year history of actinic keratoses treated [...]

A travelling bather's dermatosis: cutaneous larva migrans

Abstract Background Cutaneous larva migrans (CLM) is the clinical manifestation of the penetration of human skin by peculiar nematode larvae. In the last few years this condition has been increasingly reported among travellers returning after bathing in tropical regions. Patients Thirteen patients affected by localized or diffuse CLM have been studied. Treatment and Results Twelve patients were treated with a topical 10% thiabendazole preparation, wherease one patient with multiple lesions needed oral administration of Ivermectin.

Post-erythema nodosum localized acquired hypertrichosis

A 27‐year‐old woman presented with erythema nodosum on her legs. After treatment, only slight hyperpigmentation persisted at the sites of the previous erythema nodosum patches. Three months later the patient observed, at the same sites, the growth of dense tufts of fine black hairs.