Gabriele Ginter

An intermittent itraconazole 1-week dosing regimen for the treatment of toenail onychomycosis in dermatological practice.

Summary. The efficacy and safety of an intermittent itraconazole dosing regimen was investigated in 354 patients with toenail onychomycosis, from 98 dermatology centres. Patients received itraconazole 400 mg daily for 1 week per month for 3 months. If the nail of the big toe was completely involved, a fourth treatment cycle was administered. Because of the short‐term nature of the dosing regimen, renal and liver function tests were not compulsory. Cure rates were influenced by proximal nail involvement, particularly in the big toenails. At the end of month 10, clinical cure (complete clearance or clearance with a few small residual lesions) was achieved in 64% of patients with proximal nail involvement in the big toenails, in 77% of patients with proximal nail involvement in other toenails and in 87% of patients without proximal nail involvement; mycological cure was achieved in 77% of 197 patients examined. Fifty‐nine patients (17%) reported adverse events: mainly headache, fatigue or minor gastrointestinal problems; only nine patients (3%) stopped treatment because of adverse events. Response rates were similar to those achieved with 3 months of continuous therapy with itraconazole or terbinafine but intermittent therapy is probably safer and is considerably cheaper than continuous itraconazole treatment.

Efficacy and safety of itraconazole use in children

Current dosing regimens for itraconazole are effective, safe, and versatile for use in superficial fungal infections in children, particularly tinea capitis. Good efficacy rates have been noted in both Trichophyton and Microsporum tinea capitis infections. Itraconazole has a high affinity for keratin, and accumulates to high levels at the site of superficial fungal infections. A pulse regimen may be chosen over continuous dosing, because the accumulation persists after dosing of itraconazole has been stopped. An oral solution of itraconazole is available, and may be more convenient for children who cannot swallow capsules. The oral solution also produces good rates of efficacy, but may be associated with a somewhat higher potential for gastrointestinal adverse events than the capsules. The range of adverse events noted with itraconazole capsules or oral solution use in children is similar to the range in adults. Events are generally mild and transient. Attention must be taken to note any medications that the child is using, because itraconazole is associated with a range of potential drug interactions. This safety of use, in combination with itraconazoles wide antifungal spectrum and pharmacokinetic properties, which allow for shorter dosing regimens, may make itraconazole a suitable alternative to griseofulvin for pediatric superficial fungal infections.

Arthritis without grains caused by Pseudallescheria boydii

Summary. Severe infection of the knee joint by Pseudallescheria boydii in a 23–year‐old female resulted in complete destruction of the cartilaginous surface. The possibility of entry of the fungus through mild abrasions of unperforated skin is discussed. The clinical appearance is compared with that of Scedosporium prolificans. Antimy‐cotic miconazole‐itraconazole treatment, applied during a period of 4 months, was successful; no side‐effects were noted.

Case Report. Atypical cutaneous pseudallescheriosis refractory to antifungal agents

We report on a 65‐year‐old male heart transplant recipient who was otherwise in good condition. The patient was immunocompromised secondarily due to cyclosporin, prednisolone and azathioprine when widespread pustular skin lesions with erythematous margins subsequently developed on his left forearm. There was no history of trauma or septic temperature. Bacterial cultures were sterile and the results of native and cultural investigation studies were negative. A biopsy specimen of the lesion demonstrated hyalohyphomycosis with numerous septate hyphae within granulomas throughout the dermis. Subcutaneous tissues were not involved. Culture plates inoculated with pus and skin from the punch biopsy showed growth of a mould yielding Pseudallescheria boydii. Sensitivity testing was performed with miconazole, ketoconazole and itraconazole showing the best in vitro activity against P. boydii. In spite of treatment with itraconazole, the erythema and pustules continued to spread and therapy was changed to intravenous miconazole. Due to ongoing progression after 3 months of antifungal therapy surgical debridement was required. After 2 years of follow up, he had no recurrence.

Itraconazole is Effective in the Treatment of Tinea Capitis Caused by Microsporum Canis

Tinea capitis is a relatively common superficial fungal infection in children which requires oral antifungal therapy. In a prospective, open study over 24 weeks, itraconazole 5 mg/kg/day, given as capsules or as an oral suspension for a period of 2–12 weeks, was used to treat children 1–12 years of age who had M. canis tinea capitis. Children with mycologic evidence of M. canis tinea capitis were entered into the study and asked to return at week 2 and then every 2 weeks thereafter until cured, with a maximum of 12 weeks of active treatment. At each visit the scalp was sampled and the material processed for light microscopy and culture examination. An extra 2 weeks of itraconazole was prescribed if the mycology from the sample obtained on the previous visit indicated that there was still presence of the organism. Patients were administered either 2, 4, 6, 8, 10, or 12 weeks of treatment. The final follow‐up visit was at 12 weeks from the cessation of drug therapy. Laboratory blood testing was performed only if indicated by history, examination, or the development of side effects. There were 107 patients (49 boys, 58 girls; mean ± standard error = 5.6 ± 0.2 years). Thirteen of the 107 children were given the oral suspension. At week 12 from the cessation of treatment there was complete (clinical and mycologic) cure in all 107 children. Increasing age of the patient correlated significantly with the length of itraconazole capsule therapy (p = 0.03). The duration of itraconazole treatment also correlated significantly with the severity of tinea capitis at baseline (p = 0.02). Adverse effects were observed in 5 children receiving itraconazole capsules (n = 94). These were regarded as being possibly or probably due to the drug in two children (mild transient stomach ache in one and moderate diarrhea in one). The child with diarrhea stopped therapy at week 4 with complete resolution of symptoms. One of 13 children receiving the oral suspension had mild, transient diarrhea. There were no drop‐outs in this group. Laboratory testing was not required in any patient. Compliance was very good in the patient group. Itraconazole 5 mg/kg/day given either as a capsule or an oral suspension for 4–8 weeks is effective and safe in the treatment of tinea capitis caused by M. canis.

Vaginal yeast colonization and promiscuity. A study of 197 prostitutes.

Summary. In order to study the role of promiscuity in yeast colonization of the vagina we examined vaginal smears of 197 prostitutes. Forty‐two (21%) showed yeast infection on culture, and Candida albicans was isolated in 93% of these cases. This rate is comparable to the rates in reports of large series of non‐promiscuous women in the literature and does not suggest that promiscuity alone is a predisposing factor for vaginal yeast carriage. The rate of Candida infections was approximately the same in prostitutes taking oral contraceptives as in those not taking the pill (22 and 21%, respectively; P<0.05). The prevalence of vaginal yeast colonization, however, was significantly higher in prostitutes under the age of 31 (30%) as compared with those over 30 (10%; P<0.002), thus suggesting that women in the third decade of life are more prone to vaginal Candida infections than older age groups.

Microsporum canis infections in children: results of a new oral antifungal therapy.

Summary. Clinical and laboratory data from 22 children with tinea corporis and tinea capitis caused by Microsporum canis (10 tinea corporis, 12 tinea capitis), confirmed by microscopic examination and culture and partly pretreated with griseofulvin or terbinafine, are summarized. The children were treated consecutively with itraconazole in our clinic during 1994/95. The age of the children ranged between 4 and 13 years, with girls being affected much more frequently than boys. Oral, individually adapted, high‐dose treatment of 5 mg itraconazole per kg body weight proved to be successful. In all 22 children, although pretreatment with griseofulvin or terbinafine was partly unsuccessful, fungal infections could be cured clinically and also were culture negative at control examinations. In 10 children with tinea corporis treatment was performed only for 4–14 (middle 11) days. In the children with tinea capitis itraconazoie treatment was continued for 3–11 weeks. Among the six children without pretreatment, itraconazole solution was administered for 4–11 weeks (average 7.5 weeks). Of the patients in whom pretreatment was unsuccessful, four with griseofulvin and two with terbinafine, the duration of the subsequent oral treatment with itraconazole solution was 3–5 weeks (average 3.6 weeks). The drug seemed to be well tolerated—no significant side‐effects occurred, with the exception of possible minor gastrointestinal disturbances in two patients. Laboratory values remained within normal limits.

Simulation of a mycological KOH preparation – e-learning as a practical dermatologic exercise in an undergraduate medical curriculum

Background: Mycological KOH preparation is one of the most popular practical laboratory skills in dermatology. The study addresses the question whether an interactive simulation program enhances knowledge of students about this procedure.

Simulation des direkten KOH‐Pilzbefundes – E‐Learning einer praktischen dermatologischen Fertigkeit im Studium der Humanmedizin

Hintergrund: Der direkte Pilzbefund gehort zu den wichtigsten praktischen Tatigkeiten in der Dermatologie. (Â…Die Autoren) entwickelten eine interaktive Computersimulation und testeten deren Lerneffektivitat. Methodik: An dieser Untersuchung nahmen 166 Studierende teil, 107 weibliche und 59 mannliche. Zuerst listeten die Studierenden die ihnen bekannten Schritte des direkten Pilzbefundes auf, absolvierten anschliesend dreimal die Simulation und erstellten danach neuerlich eine Liste der notwendigen Schritte. Optional konnten sie Freitext-Feedback geben. Die Auswertung erfolgte uber Inhaltsanalyse. Ergebnis: Vor der Simulation listeten die Studierenden im Mittel 3,1 +- 2,2 Schritte auf, nach der Simulation dagegen 8,8 +- 1,2 Schritte (p < 0,001). Unterschiede zwischen den Geschlechtern gab es keine und bei der Analyse des Feedbacks uberwogen mit 78,3% die positiven Urteile gegenuber 1,8% kritischen Aussagen. Schlussfolgerung: Die Studie zeigt einen signifikanten Wissenszuwachs der Studierenden auf Grund einer interaktiven Simulation beim Erlernen des direkten Pilzbefundes sowie eine auserordentlich positive Akzeptanz. (DIPF/ Orig.)