Diagnosis and management of common tinea infections

The estimated lifetime risk of acquiring a dermatophyte infection is between 10 and 20 percent. Recognition and appropriate treatment of these infections reduces both morbidity and discomfort and lessens the possibility of transmission. Dermatophyte infections are classified according to the affected body site, such as tinea capitis (scalp), tinea barbae (beard area), tinea corporis (skin other than bearded area, scalp, groin, hands or feet), tinea cruris (groin, perineum and perineal areas), tinea pedis (feet), tinea manuum (hands) and tinea unguium (nails). To determine the best treatment approach, the physician must consider several factors: (1) the anatomic locations of the infection, (2) the safety, efficacy and cost of treatment options and (3) the likelihood that the patient will comply with treatment. Newer medications in both oral and topical forms, including imidazoles and allylamines, have greatly increased the cure rate for tinea infections. Certain types of tinea may be treated with "pulse" regimens; these innovative therapies lower treatment costs and improve patient compliance.     

Ketoconazole 2 percent cream in the treatment of tinea pedis, tinea cruris, and tinea corporis

Thirty-five dermatologists enrolled 256 patients to assess the safety and efficacy of ketoconazole 2 percent cream, applied once daily, in the treatment of tinea pedis, tinea cruris, and tinea corporis. Of these, 232 were eligible for efficacy evaluation based on mycologic evidence. Symptoms were assessed after four and eight weeks of treatment; relapse was assessed four weeks after the end of treatment. Total symptom scores decreased significantly during the treatment period. A marked or excellent response to treatment was observed in 82 percent of the cases. At the end of treatment 113 patients had all of their symptoms scored as absent or mild. Of these, three patients relapsed (2.7 percent) and had at least one symptom scored as moderate or severe at the follow-up visit. Only 7.2 percent (six of eighty-three) of the patients with negative findings on potassium hydroxide examination at the end of treatment showed positive findings at the follow-up visit. Three patients reported local irritant reactions to ketoconazole, two of whom discontinued treatment.     

Psoriasiform id reaction in tinea corporis

A case of tinea corporis due to Microsporum canis followed by a scattered psoriasiform eruption is reported. The nature, clinical features and pathogenesis of the dermatophytid are discussed.     

Superficial granulomatous pyoderma

Superficial granulomatous pyoderma (SGP) is a form of pyoderma gangrenosum (PG) characterized by superficial ulceration and chronic course. To date it has been described as a condition with specific histopathological findings. We report a new case with clinical characteristics of SGP and describe why we believe that the histological changes previously described are not typical of this entity.     

Croconazole in the treatment of tinea pedis

Croconazole hydrochloride is a new antifungal agent of the imidazole type. A 1% croconazole cream (Pilzcin, Merz + Co., D-Frankfurt/Main) was investigated in a multicentre trial involving 132 patients (mean age 46.7 +/- 15.5 years; 69 men, 63 women) suffering from tinea pedis (interdigital space, n = 86; other foot sites, n = 46). The fungal infections were caused predominantly by Trichophyton rubrum (interdigital space, n = 43; other foot sites, n = 33), followed by other Trichophyton and Candida species. The patients were treated once daily for a period of up to 3 weeks. In the majority of cases complete cure was achieved at both locations. On fungal microscopy no fungi were seen after 3 weeks in 82.6% of patients in the 'interdigital space' group and in 80.4% of patients in the 'other foot sites' group. Two weeks after the end of the treatment no fungi could be found in culture in 81.4% of the patients in the 'interdigital space' group and in 80.4% of patients in the other group. All skin symptoms of the mycoses (itching, scaling, erosions, reddening) decreased during the observation period. In 82.6% of patients in the 'interdigital space' group and in 76.1% of patients treated in the 'other foot sites' group efficacy was rated by the physician as good or very good. Tolerability was evaluated as good or very good in 90.7% and 89.1% of the cases. Local skin intolerabilities were not observed. The therapeutic results show that croconazole cream, when applied once a day, is an effective and well-tolerated drug for the treatment of tinea pedis, regardless of its location.     

Miconazole per os in tinea and deep mycosis

For the last 6 years we have been using Miconazole cream in the treatment of tinea and vaginal candidiasis. We think that it is at least as good as the best drugs for this purpose, but consider it difficult to decide about its superiority. Therefore we refrain from describing this part of our experience in detail. We have employed Miconazole "per os" at the daily doses of 24-28 mg./kg. in treating 3 cases of tinea corporis or cruris by "Trichophyton rubrum". Symptoms ceased in 3 days; mycologic examination turned negative in 2 weeks; treatment ended in apparent cure in 3 weeks. We have employed Miconazole "per venam" and "per os" in the treatment of: mycetomata (2) by "Streptomyces somaliensis", without success; mycetoma by "Madurella grisea" (1), without success; chromomycosis by a 5-flucytosine resistant strain of "Cladosporium carrionii" (1), without success; paracoccidioidosis (5) with lesions in mouth and lungs, with good results; leishmaniasis by "Leishmania brasiliensis" (1), without success; mucocutaneous disseminated candidiasis (1), with very good results. Tolerance has been excellent: but pruritus appeared from the third week with 600 or more mg. "per venam", in several patients. Doses varied between 10 and 50 mg./kg./day. One patient, who suffered with candidiasis, is taking 50 to 30 mg./kg./day since more than a year ago and, being a child, he is feeling well and growing to be normal. We recommend employing Miconazole against systemic canidiasis, sulpharesistant paracoccidioidosis and assaying it further in tinea (at least, in griseofulvin-resistant cases).     

Itraconazole responsive tinea capitis in an HIV-infected child

Cytopenias following bone marrow transplantation may be severe and life-threatening. These have been described post-allogeneic Klumpp, 1991: Bone Marrow Transplant 8:159-171. or post-autologous bone marrow transplants Khouri et al., 1994: J Clin Oncol 12:748-758. as well as with peripheral blood stem cell transplantation Klumpp et al., 1992: Am J Hematol 41:215-217. It can be immune mediated, associated on occasions with graft-versus-host disease (GVHD) Anasetti et al., 1989: Blood 4:1054-1058; however, in most cases, the underlying mechanism is uncertain. The treatment of post-transplant cytopenias is not well established, and they are often refractory to immunosuppressive therapy with steroids. Herein we describe two cases of neutropenia after allogeneic bone marrow transplantation that improved after therapy with high-dose intravenous immunoglobulin.     

The descriptive epidemiology of tinea pedis in the community

Tinea pedis is a common inflammatory skin condition due to infection by dermatophyte fungi. A number of epidemiological studies have been completed on the frequency of tinea pedis in the community, particularly sporting and occupational groups and schools. Most studies have focused on small, high-risk populations. These include occupational groups involving manual labour, sporting groups such as swimmers, and those working or living in confined conditions with shared washing facilities, which favour the opportunity for cross-infection. Most studies show that the frequency of tinea pedis is higher in males than females. Tinea pedis infections appear to be least common among children, but do occur, and are commonly misdiagnosed. The difference between clinical disease and confirmed diagnosis by culture is not always clear when statistics of disease frequency have been presented. Clear diagnosis criteria indicating the level of mycologically confirmed diagnosis should be reported in future studies that include statistics on disease frequency. Future epidemiological studies should also aim to be population-based in order to obtain a more complete picture of disease frequency.     

Efficacy of itraconazole in children with Trichophyton tonsurans tinea capitis

The microbiology of needle aspirates from 40 inflamed cervical lymph glands was studied for aerobic and anaerobic bacteria, fungi and mycobacteria. Forty-two bacterial, 11 mycobacterial and six fungal isolates were isolated. Aerobic bacteria only were recovered in 11 (27.5%), anaerobes alone in five (12.5%) and mixed aerobic and anaerobic bacteria in seven (17.5%). Mycobacterium sp. were recovered in 11 (27.5%) and fungi in six (15%). The recovery of anaerobes was associated with dental infection. Eighteen aerobic bacteria were isolated and the predominant ones were Staphylococcus aureus (eight isolates) and group A streptococci (four). Twenty-four anaerobic bacteria were recovered and the predominant ones were: Prevotella sp. (six), Peptostreptococcus sp. (five), Propionibacterium acnes (four) and Fusobacterium sp. (three). These findings demonstrate the role of anaerobic organisms in cervical lymphadenitis and the need to culture aspirated material from the glands for both aerobic and anaerobic microorganisms.     

Superficial hemangiomas: associations and management

A new design of single tooth implant (AstraTech, Molndal Sweden) featuring a microthreaded conical neck and TiO blast surface was evaluated clinically and radiographically after 2 years in function. Fifteen patients (age range 16 to 48) with missing maxillary anterior teeth (6 central incisors, 8 laterals, 1 bicuspid) had 4, 13 mm and 11, 15 mm implants placed under local anaesthesia and left for a period of 6 months before exposure and abutment connection/crown fabrication. All patients were seen at 4 to 6 monthly intervals for hygienist maintenance. Radiographs using Rinn holders and a long cone technique were taken at the crown insertion and after 1 year (14 subjects) and 2 years (12 subjects). All implants were successfully integrated at stage 2, and no implants have been lost. The internal conical seal design of the abutment/implant interface facilitated connection and there were no cases of abutment screw loosening. No soft tissue problems were observed, and the gingival morphology/health was well maintained. One crown was recemented after 18 months in function, and 1 crown was replaced because of a fracture to the porcelain incisal edge. At crown insertion, the mean bone level was 0.46 to 0.48 mm apical to the top of the implant and there were no statistically significant changes in the bone level over the 2 years of the study. In conclusion, the single tooth Astra implants were highly successful and bone changes within the first 2 years of function were comparable with other systems reporting high long-term success rates.