Cutaneous adverse effects associated with terbinafine therapy: 10 case reports and a review of the literature

Severe drug eruption from oral terbinafine for mild onychomycosis-A case report from family practice and literature review: "Just an innocent little pill?"

Onychomycosis is the most prevalent nail disease and is frequently encountered in clinical practice. Despite having multiple therapeutic options, of which systemic antifungals are the most effective, treatment is not always mandatory in all patients. Especially when considering systemic treatment, the risk of adverse reactions may outweigh the potential benefits of treatment. In this case report, we present a clinical case of a 49-year-old male patient with a blank past medical history who experienced a severe drug eruption from terbinafine prescribed for mild onychomycosis that required discontinuation of terbinafine, additional evaluation, and treatment of this adverse reaction.

Effectiveness and safety of oral terbinafine for dermatophyte distal subungual onychomycosis

INTRODUCTION

Terbinafine has been a cornerstone in dermatophyte infection treatment. Despite its global efficacy, the emergence of terbinafine resistance raises concerns, requiring ongoing vigilance.

AREAS COVERED

This paper focuses on evaluating the efficacy and safety of terbinafine in treating dermatophyte toenail infections. Continuous and pulse therapies, with a 24-week continuous regimen and a higher dosage of 500 mg/day have demonstrated superior efficacy to the FDA approved regimen of 250 mg/day x 12 weeks. Pulse therapies, though showing comparable effectiveness, present debates with regards to their efficacy as conflicting findings have been reported. Safety concerns encompass hepatotoxicity, gastrointestinal, cutaneous, neurologic, hematologic and immune adverse-effects, and possible drug interactions, suggesting the need for ongoing monitoring.

EXPERT OPINION

Terbinafine efficacy depends on dosage, duration, and resistance patterns. Continuous therapy for 24 weeks and a dosage of 500 mg/day may enhance outcomes, but safety considerations and resistance necessitate individualized approaches. Alternatives, including topical agents and alternative antifungals, are to be considered for resistant cases. Understanding the interplay between treatment parameters, adverse effects, and resistance mechanisms is critical for optimizing therapeutic efficacy while mitigating resistance risks. Patient education and adherence are vital for early detection and management of adverse effects and resistance, contributing to tailored and effective treatments.

Development of Solvent-Free Co-Ground Method to Produce Terbinafine Hydrochloride Cyclodextrin Binary Systems; Structural and In Vitro Characterizations

Molecular complexation with cyclodextrins (CDs) has long been a known process for modifying the physicochemical properties of problematic active pharmaceutical ingredients with poor water solubility. In current times, the focus has been on the solvent-free co-grinding process, which is an industrially feasible process qualifying as a green technology. In this study, terbinafine hydrochloride (TER), a low solubility antifungal drug was used as a model drug. This study aimed to prepare co-ground products and follow through the preparation process of the co-grinding method in the case of TER and two amorphous CD derivatives: (2-hydroxypropyl)-β-cyclodextrin (HPBCD); heptakis-(2,6-di-O-methyl)-β-cyclodextrin (DIMEB). For this evaluation, the following analytical tools and methods were used: phase solubility studies, differential scanning calorimetry (DSC), X-ray powder diffractometry (XRPD), hot-stage X-ray powder diffractometry (HOT-XRPD), Fourier-transform infrared (FT-IR), Raman spectroscopy, and Scanning Electron Microscopy (SEM). Furthermore, in vitro characterization (dissolution and diffusion studies) was performed in two kinds of dissolution medium without enzymes. In the XRPD and SEM studies, it was found that the co-grinding of the components resulted in amorphous products. FT-IR and Raman spectroscopies confirmed the formation of an inclusion complex through the unsaturated aliphatic chain of TER and CDs. In vitro characterization suggested better dissolution properties for both CDs and decreased diffusion at higher pH levels in the case of HPBCD.

Atypical pityriasis rosea in a young Colombian woman. Case report

Introduction: Pityriasis rosea is an acute and self-limited exanthemfirst described by Gilbert in 1860. Its treatment is symptomatic, and although there is no conclusive evidence, it has been associated with the reactivation of the human herpesviruses 6 and 7 (HHV-6 and HHV-7). Case presentation: A 28-year-old woman, from Bogotá, Colombia, ahealth worker, attended the emergency room due to the onset ofsymptoms that began 20 days earlier with the appearance of punctiformlesions in the left arm that later spread to the thorax, abdomen, opposite arm, and thighs. The patient reported a history of bipolar II disorder and retinal detachment. After ruling out several infectious diseases, and due to the evolution of the symptoms, pityriasis rosea was suspected. Therefore, treatment was started with deflazacort 30mg for 21 days, obtaining a favorable outcome and improvement of symptoms after 2 months. At the time of writing this case report, the patient had not consulted for recurrence. Conclusion: Primary care physicians should have sufficient training indermatology to recognize and treat dermatological diseases since manyof them are diagnosed based on clinical findings. This is an atypicalcase, in which the patient did not present with some of the pathognomonic signs associated with pityriasis rosea.

Risk of Psoriasis Following Terbinafine or Itraconazole Treatment for Onychomycosis: A Population-Based Case-Control Comparative Study

INTRODUCTION

Several case studies have reported an association between antifungal drug use and psoriasis risk.

OBJECTIVE

The objective of this study was to investigate the association between terbinafine/itraconazole exposure and psoriasis incidence.

METHODS

Among patients with onychomycosis in the Taiwan National Health Insurance Research Database, 3831 incident psoriasis cases were identified during 2004-2010 and compared with 3831 age- and sex-matched controls with the same look-back period. Multivariate conditional logistic regression was used for the analysis.

RESULTS

The psoriasis cases were significantly more likely than matched controls to have used terbinafine or itraconazole (59.85 vs. 42.70%, respectively; p < 0.0001). After adjusting for potential confounders and cumulative duration of antifungal drug prescription, terbinafine/itraconazole use was associated with an increased psoriasis risk (adjusted odds ratio 1.33, 95% confidence interval 1.15-1.54). The association was stronger for more recent drug exposure (adjusted odds ratio 2.96, 95% confidence interval 2.25-3.90 for ≤ 90 days before the sampling date; adjusted odds ratio 1.04, 95% confidence interval 0.89-1.22 for > 360 days). In a comparison of patients receiving terbinafine or itraconazole only, psoriasis risk was higher for itraconazole (adjusted odds ratio 1.21, 95% confidence interval 1.05-1.40).

CONCLUSION

This large population-based case-control analysis showed that exposure to terbinafine or itraconazole is associated with an increased risk of incident psoriasis. The finding of an increased psoriasis risk for antifungal drug users, particularly for itraconazole, deserves attention in clinical practice although further prospective studies are necessary to confirm our findings and clarify the biological mechanisms that underlie these associations.

Successful Treatment of Canine Sporotrichosis with Terbinafine: Case Reports and Literature Review

Sporotrichosis occurs worldwide, and the metropolitan region of Rio de Janeiro, Brazil, is a main endemic area, with a large number of human and animal cases in the last 19 years. This mycosis is more frequently described in cats rather than in dogs. There are a limited number of oral antifungal agents for the treatment of sporotrichosis in animals. In this context, the effectiveness of terbinafine in the treatment of sporotrichosis in humans, as well as the promising results of in vitro susceptibility tests, inspired us to use this drug in the therapy of this mycosis in dogs. We reported for the first time the use of terbinafine in the treatment of two dogs with sporotrichosis caused by Sporothrix brasiliensis. Moreover, we provided an overview of therapeutic features of canine sporotrichosis cases reported since the 1960s. One of the dogs presented the fixed cutaneous form of the disease, while the other patient presented hyperemia of the nasal mucosa and respiratory signs only. Terbinafine showed high antifungal activity in vitro against the canine Sporothrix isolates. The dogs were successfully treated with terbinafine, with remission of all clinical signs initially presented. The current reports indicate that this drug can emerge as a therapeutic option for canine sporotrichosis.

Clinical variants of pityriasis rosea

Pityriasis rosea (PR) is a common erythemato-squamous dermatosis which almost always, is easily diagnosed. Mostly the disease presents in its classical form. However, clinical dermatology is all about variations and PR is not an exception. Variants of the disease in some cases may be troublesome to diagnose and confuse clinicians. Prompt diagnosis and treatment of the condition becomes necessary to avoid unnecessary investigations. We hereby review and illustrate atypical presentations of the disease, including diverse forms of location and morphology of the lesions, the course of the eruption, and its differential diagnoses.

Terbinafine induced pityriasis rosea-like eruption

Terbinafine is an allylamine antifungal agent which is widely used for the treatment of fungal infections. Cutaneous side effects have been reported in 2% of the patients on terbinafine therapy with many morphological patterns. We report a case of terbinafine induced pityriasis rosea, a very rare side effect of terbinafine. This report emphasizes the importance of counseling the patient to report immediately in the event of a cutaneous eruption.

Oral Terbinafine-Induced Bullous Pemphigoid

OBJECTIVE:

To report a case of drug-induced bullous pemphigoid (BP) in an otherwise healthy elderly patient after taking terbinafine for 20 days.

CASE SUMMARY:

A 78-year-old man presented with distal subungual onychomycosis of the toenails. Oral terbinafine 250 mg/d was started for treatment. Twenty days after the beginning of the treatment, the patient presented with widespread pruritic blistering eruption, more severe on the extremities. He had not received terbinafine before and was not receiving any other drug. The diagnosis of BP was confirmed with histopathologic examination. The patient was treated successfully with oral steroids.

DISCUSSION:

Drug-induced BP is a well-known complication of many drugs and represents a spectrum from an acute and self-limited condition to a chronic disease. Terbinafine is frequently used in the elderly. It is known to have less drug interactions and adverse effects compared with the other antifungal agents. Use of the Naranjo probability scale indicated a probable relationship between BP and terbinafine treatment in this patient.

CONCLUSIONS:

To the best of our knowledge, this is the first report in the English-language literature of BP in a patient taking terbinafine. As with any other medication, oral terbinafine has the potential for severe adverse reactions. Healthcare professionals should be aware of this possibility.

Anti-trichophyton activity of protocatechuates and their synergism with fluconazole

Dermatophytosis and superficial mycosis are a major global public health problem that affects 20–25% of the world's population. The increase in fungal resistance to the commercially available antifungal agents, in conjunction with the limited spectrum of action of such drugs, emphasises the need to develop new antifungal agents. Natural products are attractive prototypes for antifungal agents due to their broad spectrum of biological activities. This study aimed to verify the antifungal activity of protocatechuic acid, 3,4-diacetoxybenzoic, and fourteen alkyl protocatechuates (3,4-dihydroxybenzoates) against Trichophyton rubrum and Trichophyton mentagrophytes and to further assess their activities when combined with fluconazole. Susceptibility and synergism assays were conducted as described in M38-A2 (CLSI), with modifications. Three strains of Trichophyton rubrum and three strains of Trichophyton mentagrophytes were used in this work. The pentyl, hexyl, heptyl, octyl, nonyl, and decyl protocatechuates showed great fungicidal effects, with minimum inhibitory concentration (MIC) values ranging from 0.97 to 7.8 mg/L. Heptyl showed a synergistic activity (FIC index = 0.49), reducing the MIC of fluconazole by fourfold. All substances tested were safe, especially the hexyl, heptyl, octyl, and nonyl compounds, all of which showed a high selectivity index, particularly in combination with fluconazole. These ester associations with fluconazole may represent a promising source of prototypes in the search for anti-Trichophyton therapeutic agents.

Pityriasis rosea: an update with a critical appraisal of its possible herpesviral etiology

Pityriasis rosea is an acute, self-healing exanthem characterized by oval erythematous-squamous lesions of the trunk and limbs, that usually spares face, scalp, palms, and soles. Constitutional symptoms, which have the character of true prodromes; clinical features, which resemble those of the known exanthems; and many epidemiologic data all suggest an infectious origin. A host of infectious agents have been incriminated, but, recently, human herpesvirus 6 and 7 have been extensively studied. The goal of this review is to outline the epidemiologic, clinical, histologic, and ultrastructural features of pityriasis rosea, but mainly to stress its possible human herpesvirus nature. In addition, clues have been added to help the reader to go through the complex subtleties of the virologic investigation.

Drug-Induced Psoriasis: An Evidence-Based Overview and the Introduction of Psoriatic Drug Eruption Probability Score

Psoriasis is a common skin disorder that needs a long-term management, not only because, of its prevalence but also because of the profound impact it can have on patients quality of life. Drugs may result in exacerbation of a preexisting psoriasis, in induction of psoriatic lesions on clinically uninvolved skin in patients with psoriasis, or in precipitation of the disease in persons without family history of psoriasis or in predisposed individuals. The knowledge of the drugs that may induce, trigger, or exacerbate the disease is of primary importance in clinical practice. By reviewing the literature, there are many reports on drug-induced psoriasis, but the data are not univocal. We propose, when possible, the use of a probability score from the authors to obtain a better classification and further understanding of drug-induced psoriasis.

Pitiríase rósea

Pitiríase rósea é doença inflamatória aguda da pele, que regride espontaneamente, normalmente sem deixar seqüelas, em período que varia de quatro a oito semanas. Clinicamente é caracterizada pelo aparecimento de típicas lesões eritêmato-pápulo-escamosas. Atinge todas as idades, embora seja mais comumente observada entre 10 e 35 anos. Apesar de exaustivas pesquisas, sua etiologia ainda permanece desconhecida. São discutidos alguns aspectos epidemiológicos, anatomoclínicos, diagnósticos diferenciais, doenças associadas, com ênfase no tratamento e etiologia da doença.

In vitro activity of Penicillium chrysogenum antifungal protein (PAF) and its combination with fluconazole against different dermatophytes

Strains of five dermatophyte species (Microsporum canis, Microsporum gypseum, Trichophyton mentagrophytes, Trichophyton rubrum and Trichophyton tonsurans) were selected for testing against Penicillium chrysogenum antifungal protein (PAF) and its combination with fluconazole (FCZ). Inhibition of microconidia germination and growth was detected with MICs of PAF ranging from 1.56 to 200 microg ml(-1) when it was used alone, or at constant concentration (100 microg ml(-1)) in combination with FCZ at from 0.25 to 32 microg ml(-1). The MICs for FCZ were found to be between 0.25 and 128 microg ml(-1). PAF caused a fungicidal effect at 200 microg ml(-1) and reduced growth at between 50 and 200 microg ml(-1). Total growth inhibition with fungistatic activity was detected at 64 microg ml(-1) of FCZ for M. gypseum, T. mentagrophytes, and T. tonsurans, and at 32 microg ml(-1) FCZ for M. canis and T. rubrum. PAF and FCZ acted synergistically and/or additively on all of the tested fungi except M. gypseum, where no interactions were detected.

Evaluation of persistence of terbinafine in the hair of normal cats after 14 days of daily therapy

This study determined the residual concentration of terbinafine in cat hair after 14 days of oral treatment. Ten clinically normal cats were administered terbinafine orally at a daily dose of 34-45.7 mg kg(-1) for a total of 14 days. Areas of 15 cm(2) were shaved on the lateral thorax at day 0 and weekly for 8 weeks after the last dose of terbinafine. The hair samples were analysed by high-pressure liquid chromatography to determine the persistence of terbinafine over time. The mean terbinafine concentration in hair was 2.30 ng mg(-1) after 14 days of therapy. The half life was 1.84 weeks after the last dose of terbinafine. With a 99% confidence interval, the concentration of terbinafine remained in the cat hair at or above 0.03 ng mg(-1) (minimal inhibitory concentration (MIC)(90) = 0.03 microg mL(-1)) for 5.3 weeks. Slight deviations in the complete blood cell count and serum chemistry values were not attributed to terbinafine. Four cats experienced vomiting during the terbinafine treatment; two of these cats also experienced intense facial pruritus followed by a macular to papular skin reaction 7-14 days after the discontinuation of terbinafine. In summary, terbinafine persists in hair at concentrations above the MIC for several weeks after stopping medication, even after short-term therapy (14 days). These results suggest that pulse therapy of terbinafine should be further researched and potentially considered as a treatment modality for feline dermatophytosis, an approach that would decrease treatment duration while maintaining effectiveness.

Generalized pustular psoriasis and hepatic dysfunction associated with oral terbinafine therapy

We report a case of 61-yr-old man with stable psoriasis who progressively developed generalized pustular eruption, erythroderma, fever, and hepatic dysfunction following oral terbinafine. Skin biopsy was compatible with pustular psoriasis. After discontinuation of terbinafine and initiating topical corticosteroid and calcipotriol combination with narrow band ultraviolet B therapy, patient's condition slowly improved until complete remission was reached 2 weeks later. The diagnosis of generalized pustular psoriasis (GPP) induced by oral terbinafine was made. To our knowledge, this is the first report of GPP accompanied by hepatic dysfunction associated with oral terbinafine therapy.

Terbinafine-Induced Subacute Cutaneous Lupus Erythematosus

BACKGROUND

Nearly 10% of lupus erythematosus (LE) are drug induced. More than 60 different drugs are involved in iatrogenic LE. We report herein 3 cases of terbinafine-induced LE.

OBSERVATIONS

Three patients receiving terbinafine for a suspected dermatophytic infection developed a subacute cutaneous LE, within 7 weeks following terbinafine introduction. The patients' medical history included sicca syndrome, lung carcinoma and Kikuchi disease, respectively. Clinical remission occurred within 15 weeks following terbinafine withdrawal.

DISCUSSION

Sixteen cases of terbinafine-induced LE have been previously reported, including 13 women. The median age was 54 years. Prior autoimmunity was reported in 10 cases, including 5 pre-existing LE. The median delay between terbinafine introduction and LE onset was 5 weeks. The median time until clinical recovery following terbinafine withdrawal was 8 weeks.

CONCLUSION

Terbinafine should be prescribed only in patients with proven dermatophytosis. We recommend cautious monitoring in patients with pre-existing autoimmunity. The diagnosis of terbinafine-induced LE should lead to the immediate and definitive withdrawal of the drug.

Antifungal activity of Ocimum gratissimum towards dermatophytes

The development of more effective and less toxic antifungal agents is required for the treatment of dermatophytosis. Plants and their preparations have been used as medicines against infectious diseases. Extracts of Ocimum gratissimum leaves were investigated for in vitro antifungal activity, using agar dilution technique against dermatophytes. The extracts (hexane, chloroform fractions, the essential oil and eugenol) produced antifungal activities against Microsporum canis, M. gypseum, Trichophyton rubrum and T. mentagrophytes. Trichophyton rubrum, the most common aetiological agent of dermatophytosis in Goiânia, state of Goiás, Brazil, was also the most susceptible dermatophyte. The hexane fraction and eugenol were the most active. Hexane fraction inhibited the growth of 100% of dermatophytes at a concentration of 125 microg ml(-1), while eugenol inhibited the growth of 80% of dermatophytes at this same concentration. These results show that extracts of O. gratissimum are active in vitro against human pathogenic dermatophytes.

Atypical presentations of pityriasis rosea: case presentations

Atypical cases of pityriasis rosea (PR) are fairly common and less readily recognized than typical eruptions. We present four patients for whom we believe atypical PR is the most likely diagnosis. A 33-year-old man had purpuric lesions bilaterally on the legs with classical rash on the trunk. A 28-year-old woman had intensely pruritic and urticarial lesions. A 10-year-old girl had hundreds of small papular lesions 1-3 mm in size. A pregnant woman aged 26 had oral haemorrhagic ulcers with classical PR eruption on her trunk. The oral ulcers erupted and remitted at the same time as the generalized eruption. We reviewed the literature and proposed a classification based on rash morphology, rash size, rash distribution, number of lesions, site of lesions, severity of symptoms and course of the eruption. We believe that it is difficult to make a clear division to define typical and atypical PR, and that it is important not to ascribe any unusual or atypical skin eruption with PR unless other dermatoses have been excluded.

Life-threatening erythroderma: diagnosing and treating the “red man”

Exfoliative erythroderma, or diffuse erythema and scaling of the skin, may be the morphologic presentation of a variety of cutaneous and systemic diseases. Establishing the diagnosis of the underlying disease is often difficult and, not uncommonly, erythroderma is classified as idiopathic. Several cases are presented to demonstrate the diversity of presentation of this disease. Laboratory findings are typically unhelpful in establishing the etiology of erythroderma. Clinical data combined with multiple skin biopsies over time are necessary. Systemic complications of erythroderma include infection, fluid and electrolyte imbalances, thermoregulatory disturbance, high output cardiac failure, and acute respiratory distress syndrome. The initial approach to the management of erythroderma of any etiology includes attention to nutrition, fluid and electrolyte replacement, and the institution of gentle local skin care measures. Oatmeal baths and wet dressings to weeping or crusted sites should be followed by application of bland emollients and low-potency topical corticosteroids. Systemic dermatologic therapy may be required to maintain improvement achieved with local measures or to control erythroderma refractory to local measures. The prognosis of erythroderma is dependent on the underlying etiology.

Evaluation of Antifungal Activity of Piper solmsianum C. DC. var. solmsianum (Piperaceae)

We have studied the crude methanolic extract (CME), some fractions (hexane, dichloromethane and ethyl acetate) and four pure compounds: eupomatenoid-3 (1), eupomatenoid-5 (2), conocarpan (3) and orientin (4), from Piper solmsianum, for possible antifungal activity against 12 pathogenic fungi. The minimal inhibitory concentration (MIC) was determined and the experiments showed that the CME exhibited antifungal action against all the dermatophytes tested, with MIC values of between 20 microg/ml to 60 microg/ml. Similar activity also was verified for the hexane, dichloromethane and ethyl acetate fractions. However, the starting material (CME), and all the fractions, did not exert inhibitory effect against hyaline hyphomycetes and were only discretely active against the zigomycetes and yeasts. Compounds 2, 3 and 4 also exhibited pronounced activity against all the dermatophytes tested (MIC< or =1 to 9 microg/ml) with potency as high as the standard antifungal drug (ketoconazole). Compound 3 also exhibited activity against all the yeasts tested. In conclusion, the antifungal activity of P. solmsianum seems to be related mainly to the presence of compounds 2, 3 (neolignans) and 4 (flavonoid), however it was verified that another active compound, as yet unidentified, exists in the plant.

Erythema multiforme during cytomegalovirus infection and oral therapy with terbinafine: a virus-drug interaction

The authors report a case of erythema multiforme in a 32-year-old woman who was also taking oral terbinafine for an onychomycosis. The patient data analysis showed serological positivity for cytomegalovirus (IgM and IgG) and hepatitis C virus and serological titre of antinuclear antibody was elevated. After a brief review of the literature the authors propose the possibility of virus-drug interaction as a model of adverse drug reactions.

Differential diagnosis of severe cutaneous drug eruptions

Adverse cutaneous reactions to drugs are frequent, mostly secondary to antibacterials, however, serious adverse cutaneous reactions are infrequent. Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are a spectrum of the same disease. They are the more severe drug eruptions, with a mortality around 30% for TEN. The confusion between erythema multiforme major and SJS means that erythema multiforme major is the main differential diagnosis. Skin disorders involving desquamation, in particular after pustulosis, are also common differential diagnoses. Mechanical or autoimmune blistering are also potential misdiagnoses of TEN/SJS. Hypersensitivity Syndrome (HSS) or Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) is a severe cutaneous drug reaction with often a long duration of eruption and serious other organ involvement. Exfoliative dermatitis, whether caused by psoriasis, dermatitis or lymphoma, can be thought of as a differential diagnosis of DRESS/HSS. Angio-immunoblastic lymphadenopathy, viral eruption and vasculitis are other differential diagnoses of DRESS/HSS. Prompt recognition of a severe drug reaction and withdrawal of the culprit drug is often the most important therapeutic action. Alternatively, a delay in starting a specific treatment for a disease misdiagnosed as a drug eruption could be deleterious.

Antimicrobial activity of Hyptis ovalifolia towards dermatophytes

The essential oil and the aqueous, hexane and methanolic fractions from Hyptis ovalifolia leaves were evaluated for their antifungal activity in vitro against 60 strains of dermatophytes: 10 strains of Microsporum canis, 10 of M. gypseum, 20 of Trichophyton rubrum and 20 of T. mentagrophytes. The extracts inhibited growth of the dermatophytes tested at different concentrations. The most biologically active was the essential oil from the leaves which inhibited 57 isolates (95%) at a concentration of 500 g/ml.

Antifungal therapy--state of the art at the beginning of the 21st century

The most relevant information on the present state of the art of antifungal chemotherapy is reviewed in this chapter. For dermatomycoses a variety of topical antifungals are available, and safe and efficacious systemic treatment, especially with the fungicidal drug terbinafine, is possible. The duration of treatment can be drastically reduced. Substantial progress in the armamentarium of drugs for invasive fungal infections has been made, and a new class of antifungals, echinocandins, is now in clinical use. The following drugs in oral and/or intravenous formulations are available: the broad spectrum polyene amphotericin B with its new "clothes"; the sterol biosynthesis inhibitors fluconazole, itraconazole, and voriconazole; the glucan synthase inhibitor caspofungin; and the combination partner flucytosine. New therapy schedules have been studied; combination therapy has found a significant place in the treatment of severely compromised patients, and the field of prevention and empiric therapy is fast moving. Guidelines exist nowadays for the treatment of various fungal diseases and maintenance therapy. New approaches interfering with host defenses or pathogenicity of fungal cells are being investigated, and molecular biologists are looking for new targets studying the genomics of pathogenic fungi.

Drug-induced urticaria. Recognition and treatment

Urticaria is the second most common cutaneous manifestation of drug allergy. Drug-induced urticaria is seen in 0.16% of medical inpatients and accounts for 9% of chronic urticaria or angioedema seen in dermatology outpatient departments. Occurring within 24 hours of drug ingestion, it is most commonly caused by penicillins, sulfonamides and nonsteroidal anti-inflammatory drugs. Drug-induced urticaria is seen in association with anaphylaxis, angioedema, and serum sickness. Diagnosis requires a detailed history, knowledge of the most likely agents sometimes supplemented with in vitro and skin testing. For mild reactions, avoidance of the causative drug and treatment with antihistamines will suffice. For anaphylactic shock, treatment with epinephrine (adrenaline), corticosteroids and antihistamines is required. Patients should be educated to inform medical staff about previous drug reactions, and to avoid these and cross-reacting drugs if possible. Medical staff need to routinely enquire about allergy and avoid unnecessary prescriptions.

Terbinafine-induced subacute cutaneous lupus erythematosus

BACKGROUND

Recently, the induction of subacute cutaneous lupus erythematosus (SCLE) and exacerbation of systemic lupus erythematosus by terbinafine have been reported.

OBJECTIVE

We describe 4 cases of SCLE, one associated with chilblain lupus, which occurred during therapy with oral terbinafine for onychomycosis.

METHODS

Of 21 consecutive patients with SCLE attending the outpatient dermatology department at Muenster University clinic during a 1-year period, 4 patients with terbinafine-induced SCLE were seen. Patients were examined fully and photographed; histologic findings as well as serologic and follow-up data were evaluated.

RESULTS

In addition to high titers of antinuclear antibodies (ANA) with a homogeneous pattern, anti-Ro(SS-A) antibodies were present; in 3 of 4 women, anti-La(SS-B) antibodies were also found. All patients had anti-histone antibodies as in drug-induced lupus and showed the characteristic genetic association of SCLE with the HLA-B8,DR3 haplotype; moreover, in 2 cases, HLA-DR2 was also present. After discontinuation of terbinafine, ANA titers decreased; anti-histone antibodies also became undetectable within 4(1/2) months in 3 patients concomitant with subsidence of the SCLE eruption in all patients.

CONCLUSION

Terbinafine is a drug that appears to infrequently induce SCLE with high titers of ANAs and anti-histone antibodies in genetically susceptible persons.

Erythroderma

Erythroderma can be caused by a variety of underlying dermatoses, infections, and systemic diseases. Many of the findings on history, physical examination, and laboratory evaluation are nondiagnostic. Distinctive clinical and laboratory features pointing to a specific disease may be evident, however. Conclusive clinicopathologic correlation may require multiple and repeated skin biopsies. The prognosis of erythroderma has improved with the advent of innovative dermatologic therapies (e.g., cyclosporine and synthetic retinoids) and advances in the management of systemic manifestations. Death from sepsis, cardiac failure, adult respiratory distress syndrome, and capillary leak syndrome continue to be rarely reported. A high index of suspicion for these complications must be maintained to facilitate early medical intervention.

Acute generalized exanthematous pustulosis associated with oral terbinafine

A case history of acute generalized exanthematous pustulosis (AGEP) following oral terbinafine is reported. A 64-year-old woman presented with a rapidly spreading micropustular eruption 3 days after completing a 28-day course of oral terbinafine. There was a positive family history of psoriasis but no personal history. The clinical presentation and histopathology were consistent with AGEP. There was nearly complete resolution of the pustular eruption within 3.5 weeks following cessation of oral terbinafine and treatment with topical and systemic corticosteroids. The patient has remained free of any recurrence 18 months later. A summary of drugs known to be associated with AGEP is presented. Prompt recognition of AGEP is stressed in order to avoid confusion with acute generalized pustular psoriasis or a systemic infection. The most important aspect of management is the immediate withdrawal of the suspect drug.

Onychomycosis. Treatment, quality of life, and economic issues

Onychomycosis is a public health concern because of its high worldwide incidence and prevalence, and its potential for spread of fungal elements to others, as well as complications such as cellulitis, bacterial infection, pain, and extensive dermatophytic infections. The incidence of onychomycosis has been increasing, particularly in individuals over 60 years of age, patients with HIV infection, and patients with diabetes mellitus. Onychomycosis may impact upon physical, functional, psychosocial, and emotional aspects of life. Difficulty walking, wearing shoes, and embarrassment are common complaints. Quantification of such quality-of-life changes are significant to clinical practice in that many factors can affect overall patient health. In light of the potential clinical implications on physical and mental health, onychomycosis should be considered a medical condition that deserves rigorous clinical management. Onychomycosis can be treated effectively and with comparative safety with the new generation of oral antifungal agents (itraconazole, fluconazole and terbinafine). Significantly improved pharmacokinetic and pharmacodynamic profiles permit markedly reduced duration of administration, individual drug exposure, and ultimately enhanced patient compliance and satisfaction with therapy. In addition, a number of pharmacoeconomic studies have documented the cost effectiveness of these newer agents compared with both traditional pharmacologic treatment and topical therapies. The currency figures quoted are 1997 values. With regard to continuous oral antifungal regimens, terbinafine therapy has been found to be most cost effective in the treatment of toenail onychomycosis, with a drug acquisition cost of $US522.50. However, improved safety, tolerability, efficacy and cost effectiveness have been documented with itraconazole intermittent, pulse regimens. With itraconazole pulse therapy, the drug acquisition cost decreases to $US488.90. Additionally, the total cost of medical management is less for itraconazole therapy compared with that of terbinafine ($US261.00 vs $US306.00). Because sensitivity analyses for itraconazole and terbinafine have been found to be somewhat comparable in terms of mycological cure, clinical response, and relapse rates, other variables such as safety and efficacy profiles, and patient attitudes and expectations toward therapy need to be considered when formulating an onychomycosis pharmacologic treatment plan. The drug aquisition cost of fluconazole given as a 300 mg dose once weekly for 6 months is $US562.76 and given as a 150 mg dose once weekly (for 6 months) $US281.38.

Diagnosing and treating onychomycosis

Onychomycosis is a particular concern for active people because they're exposed to fungi in locker rooms and because hot, sweaty feet enable the infection to flourish. A thorough physical exam and potassium hydroxide exam of debris from the nail plate can help rule out look-alike conditions and provide information that will guide drug therapy. Treatment with the new generation of onychomycosis medications-itraconazole, fluconazole, and terbinafine hydrochloride-is costly but produces impressive cure rates. Active patients need detailed instruction about preventive measures to avoid recurrence.