Tinea capitis: an overview with emphasis on management

Exploring treatment and antifungal resistance in an outbreak of tinea caused by Microsporum audouinii

BACKGROUND

Microsporum audouinii has resurged recently. Infections with the dermatophyte are difficult to treat, which raises the question if we treat M. audouinii infections with the most effective antifungal (AF) agent.

OBJECTIVES

The aims of this study was to investigate an outbreak of tinea capitis (TC) in Denmark, address the challenges in outbreak management and to conduct two reviews regarding previous outbreaks and minimal inhibitory concentration (MIC).

METHODS

We used Wood's light, culture, direct microscopy, and PCR for screening and antifungal susceptibility testing (AFST) for treatment optimization. We performed two reviews to explore M. audouinii outbreaks and MIC values using broth microdilution method.

RESULTS

Of 73 screened individuals, 10 had confirmed M. audouinii infections. Clinical resistance to griseofulvin was observed in 4 (66%) cases. While previous outbreaks showed high griseofulvin efficacy, our study favoured terbinafine, fluconazole and itraconazole in our hard-to-treat cases. AFST guided the choice of AF. Through the literature search, we identified five M. audouinii outbreaks, where differences in management included the use of Wood's light and prophylactic topical AF therapy. Terbinafine MIC values from the literature ranged from 0.002 to 0.125 mg/L.

CONCLUSION

Use of Wood's light and preventive measurements were important for limiting infection. The literature lacked MIC data for griseofulvin against M. audouinii, but indicated sensitivity for terbinafine. The clinical efficacy for M. audouinii treatment was contradictory favouring both terbinafine and griseofulvin. AFST could have a key role in the treatment of difficult cases, but lack of standardisation of AFST and MIC breakpoints limits its usefulness.

Scalp Infection, Inflammation, and Infestation

Tinea capitis, folliculitis, seborrheic dermatitis, and pediculosis capitis are four common scalp conditions. Although tinea capitis and seborrheic dermatitis are found more commonly in patients with skin of color and highly textured hair, all of these conditions have special diagnostic or management considerations in these populations. This article reviews the diagnosis and management of these common scalp conditions.

Tinea capitis in an immigrant pediatric community; a clinical signs-based treatment approach

Background

Tinea capitis is a common cutaneous infection of the scalp and hair follicles, typically diagnosed by direct examination and culture. Treatment with oral antifungals is usually withheld until mycology results are available. In Israel, African refugee children demonstrate higher susceptibility to Tinea capitis and generally fail to undergo follow-up evaluations.

Methods

This study aimed to identify the clinical characteristics and treatment responses of refugee children in Israel with Tinea capitis, in order to formulate a treatment plan for primary care physicians. To this end, demographic, clinical and laboratory data were extracted from the electronic medical records of 76 refugee children presenting with Tinea capitis during 2016–2017. All measured variables and derived parameters are presented using descriptive statistics. The correlation between background clinical and demographic data and Tinea capitis diagnosis was assessed using the chi-squared and Wilcoxon tests. Correlations between demographic/clinical/laboratory characteristics and other types of fungi or other important findings were assessed using a T-test.

Results

Scaling was the most common clinical finding. Cultures were positive in 64 (84%) and direct examination in 65 (85%) cases, with a positive correlation between the methods in 75% of cases. The most common fungal strain was T. violaceum. Fluconazole treatment failed in 27% of cases. Griseofulvin 50 mg/kg/day was administered to 74 (97%) children, and induced clinical responses. No side effects were reported.

Conclusions

The key aim of this study was to emphasize the importance of diagnosis and treatment of these immigrant children by their primary pediatric doctor since it takes, an average of 4.3 months until they visit a dermatologist. During this critical time period, the scalp can become severely and permanently damaged, and the infection can become systemic or cause an outbreak within the entire community. In conclusion, we recommend to relate to scaly scalp in high-risk populations as Tinea capitis, and to treat with griseofulvin at a dosage of up to 50 mg/kg/day, starting from the first presentation to the pediatrician.

Bedside Diagnostics for Infections: A Guide for Dermatologists

In dermatology, there are many bedside diagnostic tests that may aid in more rapid diagnosis and early initiation of appropriate therapy. When performed correctly, these bedside diagnostic tests can provide both sensitive and specific results. We discuss bedside diagnostic tests, such as the Tzanck smear, potassium hydroxide (KOH) preparation, and mineral oil preparation, with a specific focus on their use in diagnosing infectious dermatoses.

Low in vitro activity of sertaconazole against clinical isolates of dermatophyte

Background and Purpose:

Dermatophytes are a group of fungi specialized in invading humans and other vertebrate keratinized tissues. These fungi cause a variety of skin, nail, and hair disorders, called dermatophytosis (tinea). In some cases, drug resistance to antifungals necessitates special treatment. Among the antifungal agents, sertaconazole (i.e., a third-generation imidazole) has a broad-spectrum against dermatophyte species. Regarding this, the present study was conducted to investigate the antifungal susceptibility of dermatophytes obtained from patients with dermatophytosis in Mashhad located in northeastern Iran.

Materials and Methods:

A total of 75 clinical dermatophyte isolates, including Trichophyton mentagrophytes (n=21), T. interdigital (n=18), T. tonsurans (n=16), Epidermophyton floccosum (n=11), Microsporum canis (n=5), Nannizzia fulvum (n=2), T. benhamiae (n=1), and T. verrucosum (n=1), were evaluated against five antifungal agents of sertaconazole, itraconazole, clotrimazole, terbinafine, and griseofulvin based on the CLSI M38-A2 guideline.

Results:

According to the results, the minimum inhibitory concentration (MIC) ranges ofsertaconazole, terbinafine, griseofulvin, itraconazole, and clotrimazole were estimated at 0.125-16, 0.002-1, 0.5-4, 0.031-4, and 0.016-4 µg/ml, respectively, for dermatophyte species. In addition, the geometric mean (GM) values of the MIC of sertaconazole, terbinafine, griseofulvin, itraconazole, and clotrimazole were obtained as 3.39, 1, 1.44, 1.52, and 1.93, respectively.

Conclusion:

Among the tested antifungals, terbinafine and griseofulvin were the most effective agents against dermatophyte isolates. However, sertaconazole, a third-generation imidazole, did not show any significant effect. Furthermore, M. canis and E. floccosum showed the best response to the antifungal agents.

Distribution of Species of Dermatophyte Among Patients at a Dermatology Centre of Nghean Province, Vietnam, 2015-2016

INTRODUCTION

Vietnam is a tropical country so fungal diseases including dermatophytosis may be prevalent, but epidemiological profiles of agents responsible for the infection have rarely been reported.

OBJECTIVE

To find out the distribution of dermatophytes among patients living in a central province of Vietnam.

METHODS

We examined dermatophyte infections in patients with lesions suspected of dermatophytosis referred to the Nghean provincial leprosy and dermatology centre from August 2015 to August 2016. The speciation of dermatophyte was performed by conventional and molecular approaches.

RESULTS

One hundred and thirty-six patients (90 males and 46 females) were included. Those aged from 11 to 30 contribute 59.1%. The most common agent found was Trichophyton rubrum (66.9%), followed by T. interdigitale (12.5%), T. tonsurans (9.6%), Microsporum incurvatum (8.1%), and the less frequent species were M. canis (2.2%) and T. violaceum (0.7%). Epidermophyton floccosum was not reported. T. rubrum were more common in men (74.4%) than in women (52.2%), while T. interdigitale and M. incurvatum were more common in women (21.7 and 15.2%) than in men (7.8 and 4.4%). Patients infected with Microsporum spp. had small-sized lesions for only 3 months, while those affected by Trichophyton spp. had large-sized lesions with longer duration.

CONCLUSION

Trichophyton species are the predominant agents of infection in Nghean province, while Epidermophyton species is absent. Additional investigations are required to clarify the epidemiological profile of dermatophytes in Vietnam.

Systemic antifungal therapy for tinea capitis in children

BACKGROUND

Tinea capitis is a common contagious fungal infection of the scalp in children. Systemic therapy is required for treatment and to prevent spread. This is an update of the original Cochrane review.

OBJECTIVES

To assess the effects of systemic antifungal drugs for tinea capitis in children.

SEARCH METHODS

We updated our searches of the following databases to November 2015: the Cochrane Skin Group Specialised Register, CENTRAL (2015, Issue 10), MEDLINE (from 1946), EMBASE (from 1974), LILACS (from 1982), and CINAHL (from 1981). We searched five trial registers and checked the reference lists of studies for references to relevant randomised controlled trials (RCTs). We obtained unpublished, ongoing trials and grey literature via correspondence with experts in the field and from pharmaceutical companies.

SELECTION CRITERIA

RCTs of systemic antifungal therapy in children with normal immunity under the age of 18 with tinea capitis confirmed by microscopy, growth of fungi (dermatophytes) in culture or both.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 25 studies (N = 4449); 4 studies (N = 2637) were new to this update.Terbinafine for four weeks and griseofulvin for eight weeks showed similar efficacy for the primary outcome of complete (i.e. clinical and mycological) cure in three studies involving 328 participants with Trichophyton species infections (84.2% versus 79.0%; risk ratio (RR) 1.06, 95% confidence interval (CI) 0.98 to 1.15; low quality evidence).Complete cure with itraconazole (two to six weeks) and griseofulvin (six weeks) was similar in two studies (83.6% versus 91.0%; RR 0.92, 95% CI 0.81 to 1.05; N = 134; very low quality evidence). In two studies, there was no difference between itraconazole and terbinafine for two to three weeks treatment (73.8% versus 78.8%; RR 0.93, 95% CI 0.72 to 1.19; N = 160; low quality evidence). In three studies, there was a similar proportion achieving complete cured with two to four weeks of fluconazole or six weeks of griseofulvin (41.4% versus 52.7%; RR 0.92, 95% CI 0.81 to 1.05; N = 615; moderate quality evidence). Current evidence for ketoconazole versus griseofulvin was limited. One study favoured griseofulvin (12 weeks) because ketoconazole (12 weeks) appeared less effective for complete cure (RR 0.76, 95% CI 0.62 to 0.94; low quality evidence). However, their effects appeared to be similar when the treatment lasted 26 weeks (RR 0.95, 95% CI 0.83 to 1.07; low quality evidence). Another study indicated that complete cure was similar for ketoconazole (12 weeks) and griseofulvin (12 weeks) (RR 0.89, 95% CI 0.57 to 1.39; low quality evidence). For one trial, there was no significant difference for complete cure between fluconazole (for two to three weeks) and terbinafine (for two to three weeks) (82.0% versus 94.0%; RR 0.87, 95% CI 0.75 to 1.01; N = 100; low quality evidence). For complete cure, we did not find a significant difference between fluconazole (for two to three weeks) and itraconazole (for two to three weeks) (82.0% versus 82.0%; RR 1.00, 95% CI 0.83 to 1.20; low quality evidence).This update provides new data: in children with Microsporum infections, a meta-analysis of two studies found that the complete cure was lower for terbinafine (6 weeks) than for griseofulvin (6-12 weeks) (34.7% versus 50.9%; RR 0.68, 95% CI 0.53 to 0.86; N = 334; moderate quality evidence). In the original review, there was no significant difference in complete cure between terbinafine (four weeks) and griseofulvin (eight weeks) in children with Microsporum infections in one small study (27.2% versus 60.0%; RR 0.45, 95% CI 0.15 to 1.35; N = 21; low quality evidence).One study provides new evidence that terbinafine and griseofulvin for six weeks show similar efficacy (49.5% versus 37.8%; RR 1.18, 95% CI 0.74 to 1.88; N = 1006; low quality evidence). However, in children infected with T. tonsurans, terbinafine was better than griseofulvin (52.1% versus 35.4%; RR 1.47, 95% CI 1.22 to 1.77; moderate quality evidence). For children infected with T. violaceum, these two regimens have similar effects (41.3% versus 45.1%; RR 0.91, 95% CI 0.68 to 1.24; low quality evidence). Additionally, three weeks of fluconazole was similar to six weeks of fluconazole in one study in 491 participants infected with T. tonsurans and M. canis (30.2% versus 34.1%; RR 0.88, 95% CI 0.68 to 1.14; low quality evidence).The frequency of adverse events attributed to the study drugs was similar for terbinafine and griseofulvin (9.2% versus 8.3%; RR 1.11, 95% CI 0.79 to 1.57; moderate quality evidence), and severe adverse events were rare (0.6% versus 0.6%; RR 0.97, 95% CI 0.24 to 3.88; moderate quality evidence). Adverse events for terbinafine, griseofulvin, itraconazole, ketoconazole, and fluconazole were all mild and reversible.All of the included studies were at either high or unclear risk of bias in at least one domain. Using GRADE to rate the overall quality of the evidence, lower quality evidence resulted in lower confidence in the estimate of effect.

AUTHORS' CONCLUSIONS

Newer treatments including terbinafine, itraconazole and fluconazole are at least similar to griseofulvin in children with tinea capitis caused by Trichophyton species. Limited evidence suggests that terbinafine, itraconazole and fluconazole have similar effects, whereas ketoconazole may be less effective than griseofulvin in children infected with Trichophyton. With some interventions the proportion achieving complete clinical cure was in excess of 90% (e.g. one study of terbinafine or griseofulvin for Trichophyton infections), but in many of the comparisons tested, the proportion cured was much lower.New evidence from this update suggests that terbinafine is more effective than griseofulvin in children with T. tonsurans infection.However, in children with Microsporum infections, new evidence suggests that the effect of griseofulvin is better than terbinafine. We did not find any evidence to support a difference in terms of adherence between four weeks of terbinafine versus eight weeks of griseofulvin. Not all treatments for tinea capitis are available in paediatric formulations but all have reasonable safety profiles.

Molecular Characterization and In Vitro Antifungal Susceptibility of 316 Clinical Isolates of Dermatophytes in Iran

Dermatophytosis is a common mycotic infection of the skin, nail, and hair, associated with major public health concern worldwide. Various species of dermatophytes show significant differences in susceptibility to antifungals. Here, we present the antifungal susceptibility of a large collection of molecularly identified dermatophyte isolates obtained from tropical region of south of Iran. A total of 9485 patients clinically suspected to have cutaneous fungal infections were examined. Dermatophytosis was confirmed in 1502 cases by direct microscopy and culture. Three hundred and sixteen isolates recovered in culture were identified to species level using PCR sequencing of ITS region and RFLP. Tinea corporis was the most prevalent type of clinical manifestation (35.2 %), followed by tinea cruris (17 %), tinea capitis (12.8 %), tinea pedis (11.3 %), tinea manuum (11 %), tinea unguium (6.9 %), and tinea barbae (5.8 %). Trichophyton interdigitale was the most common isolate (49.36 %), followed by Trichophyton rubrum (18.98 %), Epidermophyton floccosum (13.29 %), Microsporum canis (9.17 %), Arthroderma benhamiae (T. anamorph of A. benhamiae; 5.38 %), and Trichophyton tonsurans (3.79 %). Overall, irrespective of the geographical region, terbinafine was the most potent antifungal against all isolates, with an MIC range of 0.002-0.25 μg/mL, followed by itraconazole (0.004-0.5 μg/mL), griseofulvin (0.125-8 μg/mL), and fluconazole (4-128 μg/mL). Analysis of our data revealed a significant increase in the frequency of A.benhamiae, which definitely warrants further investigation to explore source of this infection in south of Iran. Moreover, terbinafine was the most effective antifungal against all isolates, in vitro.

Outbreak of Microsporum audouinii in Munich--the return of infectious fungi in Germany

After experiencing an unusually high number of Microsporum (M.) audouinii infections at our hospital within only a few weeks, we began to investigate and control an outbreak in Munich, Germany. Main goals of our health management were to treat infected persons, identify extent and form of transmission and to prevent new infections. We analysed data from structured interviews with patients and mycological cultures of swabs taken of patients and investigated involved public facilities. Outbreak management included antifungal treatment of patients, decontamination of affected facilities, the introduction of a temporary kindergarten ban for M. audouinii positive children and the organisation of educational meetings. Between March and August 2011, 16 children and 4 adults were identified with M. audouinii infections. The fungus was brought to Munich by the index patients from a family vacation in Africa and then spread to fellow children in kindergarten and subsequently to their families. All patients were treated successfully and the epidemic was declared ceased after 40 weeks but causing considerable financial damage. Due to travelling and migration, M. audouinii infections will rise in Germany and Europe. Sufficient and sustainable strategies are needed for the management of future outbreaks of highly contagious fungi.

Diffuse alopecia in an adolescent female: tinea capitis

"Black dot" tinea capitis is a common cause of alopecia in young patients. It is most commonly caused by a dermatophyte infection with Trichophyton tonsurans. This entity can be easily distinguished from alopecia areata with the use of hair/scalp dermoscopy. The use of oral terbinafine is effective in resolving the infection.

Itraconazole (Sporanox®) in superficial and systemic fungal infections

Itraconazole (Sporanox) is a triazole antifungal agent with a broad activity spectrum and favorable pharmacokinetic and safety profiles. Numerous clinical trials have established the efficacy and safety of itraconazole in the treatment of superficial fungal infections. In this field, full exploitation of its pharmacokinetics in keratinized tissues has led to the development of intermittent (pulse) treatment regimens that allow similar efficacy with lower overall drug exposure as well as a reduction in treatment costs. The additional anti-inflammatory action of itraconazole also makes it suitable for application in difficult-to-treat inflammatory skin disorders, such as seborrheic dermatitis. Recently, a new oral liquid formulation and an intravenous formulation have been developed, extending the therapeutic application of itraconazole to systemic fungal infections. Due to its broad activity spectrum and excellent tolerability, itraconazole is a valuable addition to the antifungal armamentarium used for prophylactic and empiric treatment in immunocompromised hosts.

Molecular epidemiology, phylogeny and evolution of dermatophytes

Dermatophytes are fungi that invade and propagate in the keratinized skin of mammals, including humans, often causing contagious infections. The species of medical concern belong to the genera Microsporum, Trichophyton, Epidermophyton (in their anamorphic state) and Arthroderma (in their telomorphic state), which were traditionally identified based on their morphology and biochemical characters. Nonetheless, limitations linked to the differentiation of closely related agents at species and strains level have been recently overcome by molecular studies. Indeed, an accurate identification of dermatophytes is pivotal for the establishment of effective control and prevention programs as well as for determining the most appropriate and effective antifungal therapies to be applied. This article reviews the DNA techniques and the molecular markers used to identify and to characterize dermatophyte species, as well as aspects of their phylogeny and evolution. The applications of typing molecular strain to both basic and applied research (e.g., taxonomy, ecology, typing of infection, antifungal susceptibility) have also been discussed.

Identification of the Trichophyton mentagrophytes complex species using MALDI-TOF mass spectrometry

Dermatophytes are fungi capable of invading keratinized tissues and are responsible for the most common fungal infection worldwide: dermatophytosis. Identification of these organisms to the species level is often necessary for the correct treatment of these infections, and is always recommended from an epidemiological point of view. Since the identification of dermatophytes is sometimes problematic, we assessed whether Matrix-Assisted Laser Desorption/Ionization Time of Flight Mass Spectrometry (MALDI-TOF MS) could provide a useful tool to identify dermatophytes of the Trichophyton mentagrophytes complex. A reference database was constructed with 17 strains of six different species belonging to this complex. A total of 54 dermatophyte strains of the Belgian co-ordinated collections of micro-organisms, Scientific Institute of Public Health, Brussels, Belgium (BCCM™/IHEM) collection were used to challenge this database; 89% of the tested strains (not used as reference strains in the database) could readily be identified. When incorrect identifications were encountered, the confusion was always between phylogenetically closely related taxa which indicates that observations made by MALDI-TOF MS correlate with phylogenetic data. To assess this observation, a dendrogram outlining the similarities between the obtained spectra was constructed. Strikingly, the relationships found in this dendrogram were highly similar to the ones observed in the phylogenetic tree recently reported by Beguin and co-workers. In conclusion, MALDI-TOF MS is a fast and reliable tool for the identification of dermatophytes, since it can even discriminate between the closely related species of the T. mentagrophytes complex. Moreover, our data indicate that the data obtained by MALDI-TOF MS correlate with phylogenetic data.

Trichophyton tonsurans in a family microepidemic

Trichophyton tonsurans is a highly transmissible anthropophilic dermatophyte fungus, which invades keratinized tissues. This study reports a case of family microepidemic caused by this dermatophyte. Despite their excellent hygiene conditions, it remained active for several years, spreading to all family members. The hypothesis that the fungus was being kept alive in the family home was confirmed after samples collected from it were analyzed. Pure cultures of the fungus were isolated and identified. After diagnosis, the house was disinfected with concomitant oral treatment for all family members.

Systemic antifungal therapy for tinea capitis in children

BACKGROUND

Tinea capitis is a common contagious fungal infection of the scalp in children. Systemic therapy is required for treatment and to prevent spread.

OBJECTIVES

To assess the effects of systemic anti-fungal drugs for tinea capitis in children.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (June 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2005), MEDLINE (2003 to June 2005), EMBASE ( 2003 to June 2005), LILACS (1982 to July 2005), CINAHL (1982 to July 2005), the ACP journal club (1991 to July 2005) and Healthstar (1975 to July 2005).

SELECTION CRITERIA

Randomised controlled trials (RCTs) that evaluated systemic antifungal therapy in people with normal immunity under the age of 18 who had tinea capitis confirmed by microscopy or growth of dermatophytes in culture or both.

DATA COLLECTION AND ANALYSIS

At least two authors independently examined each retrieved trial for eligibility and quality.

MAIN RESULTS

We included 21 studies (1812 participants). Infections involving Trichophyton species: Terbinafine for four weeks and griseofulvin for eight weeks showed similar efficacy in 3 studies involving 382 participants (RR 1.09; 95% CI 0.95 to 1.26). Cure rates following treatment with itraconazole and griseofulvin for 6 weeks were similar in 1 study of 35 children (RR 1.06; 95% CI 0.81 to 1.39). Another study of 100 children did not show any significant difference in cure between itraconazole for 2 weeks compared with griseofulvin for 6 weeks (RR 0.89; 95% CI 0.76 to 1.04). There was no difference between itraconazole and terbinafine for treatment periods lasting 2 to 3 weeks in 2 studies involving 160 children (RR 0.93; 95% CI 0.72 to 1.19). Two studies that included 140 children found similar cure rates between 2 to 4 weeks of fluconazole with 6 weeks of griseofulvin (RR 0.92; 95% CI 0.80 to 1.05). Microsporum infections: There was no significant difference in cure between terbinafine and griseofulvin in children with Microsporum infections in 1 small study of 29 children (RR 0.64; 95% CI 0.19 to 2.20).

AUTHORS' CONCLUSIONS

The best evidence suggests that newer treatments including terbinafine, itraconazole and fluconazole may be similar to griseofulvin in children with tinea capitis caused by Trichophyton species. Newer treatments may be preferred because shorter treatment durations may improve treatment adherence, although they may be more expensive. There is not enough evidence on the use of systemic treatments in children with Microsporum infections. Not all treatments for tinea capitis are available in paediatric formulations but all have reasonable safety profiles.

Tinea capitis: ringworm of the scalp

The guideline tinea capitis, as passed by three German medical societies, is presented in the present study.

In vivo efficacy and pharmacokinetics of voriconazole in an animal model of dermatophytosis

The standard treatment for tinea capitis caused by Microsporum species for many years has been oral griseofulvin, which is no longer universally marketed. Voriconazole has been demonstrated to inhibit growth of Microsporum canis in vitro. We evaluated the efficacy and tissue pharmacokinetics of oral voriconazole in a guinea pig model of dermatophytosis. Guinea pigs (n = 16) were inoculated with M. canis conidia on razed skin. Voriconazole was dosed orally at 20 mg/kg/day for 12 days (days 3 to 14). The guinea pigs were scored clinically (redness and lesion severity) and mycologically (microscopy and culture) until day 17. Voriconazole concentrations were measured day 14 in blood, skin biopsy specimens, and interstitial fluid obtained by microdialysis in selected animals. Clinically, the voriconazole-treated animals had significantly less redness and lower lesion scores than untreated animals from days 7 and 10, respectively (P < 0.05). Skin scrapings from seven of eight animals in the voriconazole-treated group were microscopy and culture negative in contrast to zero of eight animals from the untreated group at day 14. The colony counts per specimen were significantly higher in samples from untreated animals (mean colony count of 28) than in the voriconazole-treated animals (<1 in the voriconazole group [P < 0.0001]). The voriconazole concentration in microdialysate (unbound) ranged from 0.9 to 2.0 microg/ml and in the skin biopsy specimens total from 9.1 to 35.9 microg/g. In conclusion, orally administered voriconazole leads to skin concentrations greater than the necessary MICs for Microsporum and was shown to be highly efficacious in an animal model of dermatophytosis. Voriconazole may be a future alternative for treatment of tinea capitis in humans.

Periodontal therapy in siblings with Papillon?Lef�vre syndrome and tinea capitis: a report of two cases

OBJECTIVE

Report of clinical and microbiological periodontal findings before and 6 months after treatment of two siblings with Papillon-Lefèvre syndrome (PLS) and tinea capitis.

METHODS

Two brothers, RG 3 years and NG 5 years of age, were referred for treatment due to premature mobility of their deciduous teeth. Probing depths (PPD), attachment levels (PAL-V), and furcation involvements were examined clinically. Panoramic radiographs were taken. Subgingival plaque samples within the deepest pocket of each tooth were taken and analysed by real-time polymerase chain reaction (PCR) for Actinobacillus actinomycetemcomitans (AA), Porphyromonas gingivalis, Tannerella forsythensis, Treponema denticola, Fusobacterium nucleatum, and Prevotella intermedia. One-stage full-mouth scaling and extraction of hopeless teeth were performed under general anaesthesia, followed by systemic amoxicillin and metronidazole for 7 days. Clinical and microbiological analyses were performed 6 months after treatment.

RESULTS

Before treatment, both siblings had exhibited PPD of up to 13 mm, Class III furcation defects at four teeth, and marginal suppuration. AA was detected in both patients and at all teeth at levels ranging from 3.0 x 10(2) to 5.1 x 10(6). Both patients exhibited palmar and plantar hyperkeratosis. Seven teeth were extracted from RG, and nine from NG. Six months after treatment, PPD had been reduced to <or=5 mm. AA was not detected in any of the remaining teeth.

CONCLUSION

Even periodontally affected deciduous teeth of PLS patients can be treated successfully. Suppression of AA to below detection level seems to be of high significance.

A randomized controlled trial assessing the efficacy of fluconazole in the treatment of pediatric tinea capitis

BACKGROUND

Griseofulvin is considered first-line therapy for tinea capitis, and the Physician's Desk Reference currently recommends 11 mg/kg per day microsize formulation for use in children. Diverse selective pressures have resulted in waning clinical efficacy of griseofulvin, such that higher doses and longer courses of treatment are required. These events have prompted the search for therapeutic alternatives. Fluconazole is one such treatment option, and a variety of studies using this drug have shown promise in the treatment of pediatric tinea capitis.

OBJECTIVE

We sought to assess the efficacy, safety, and optimal dose and duration of fluconazole therapy compared with standard-dose griseofulvin (11 mg/kg per day microsize formulation) in the treatment of pediatric tinea capitis.

METHODS

This randomized, multicenter, third-party-blind, 3-arm trial was designed as a superiority study to identify a therapeutically superior agent/regimen from the 3 treatment arms: (1) fluconazole 6 mg/kg per day for 3 weeks followed by 3 weeks of placebo, (2) fluconazole 6 mg/kg per day for 6 weeks, and (3) griseofulvin 11 mg/kg per day for 6 weeks. Efficacy variables included mycological, clinical, and combined outcomes. The primary efficacy variable was the combined outcome of the modified intent-to-treat population at week 6. Patient safety was assessed throughout the study. Statistical analysis of the efficacy variables was conducted by means of the Cochran-Mantel-Haenszel test.

RESULTS

At the end of treatment, mycological cures were present in 44.5%, 49.6%, and 52.2% of the fluconazole 3-week, fluconazole 6-week, and griseofulvin groups, respectively. Analysis of the primary efficacy variable failed to identify any superior agent, and differences between the combined outcomes of the fluconazole 6-week and griseofulvin groups at week 6 were not significant (P = .32). Regarding mycological, clinical, and combined outcomes, no significant differences between the fluconazole 6-week and griseofulvin groups were detected at any time point in the study. No new safety concerns were raised by this trial, and the incidence of treatment-related adverse events noted in this study is concordant with previous reports. Patients in the fluconazole arms of the study fared similarly. At the end of the trial, the difference in mycological cures between the fluconazole arms was only 7.5%, and increases in the incidence of certain treatment-related adverse events were observed in the fluconazole 6-week group.

LIMITATIONS

Adjunctive topical therapies and the impact of infected contacts were not assessed in this trial.

CONCLUSION

Systemic therapy with fluconazole 6 mg/kg per day and standard-dose griseofulvin produces comparable but low mycological and clinical cure rates. The limited efficacy of standard-dose griseofulvin and the lack of consensus regarding dose and duration of griseofulvin therapy in tinea capitis emphasize the need for controlled trials to identify optimal treatment parameters. Although the efficacy of fluconazole is no better than that of standard-dose griseofulvin, it may still be useful in select patients with a contraindication or intolerance to high-dose griseofulvin. The outcomes observed in this trial highlight the need to more clearly define the relative importance of adjunctive topical therapies and the evaluation and treatment of infected contacts as factors affecting cure rates.

Pediatric tinea capitis: recognition and management

Tinea capitis (ringworm of the head) is the most common dermatophytosis of childhood with an increasing incidence worldwide. If suspected clinically, further diagnostic procedures, including direct microscopy and culture, should be performed. Other scalp alterations, such as seborrheic dermatitis, atopic eczema, psoriasis, alopecia areata, folliculitis, and pseudopelade, may mimic ringworm of the head and must be identified. A proven fungal infection of scalp skin and hairs warrants immediate initiation of systemic treatment. At present, only oral griseofulvin is approved for therapy of scalp ringworm in children by health authorities. However, the advent of several newer antifungal agents such as itraconazole, fluconazole, and terbinafine has broadened the therapeutic armamentarium in recent years. These agents offer shorter treatment intervals, and their adverse effects and drug interaction profiles appear to be well within acceptable limits. In patients with tinea capitis, systemic therapy at weight-dependent dosages for an appropriate amount of time in conjunction with topical supportive measures will help to prevent disfiguring hair loss, permanent formation of scar tissue, spread of fungal organisms to other cutaneous regions, and infection of other persons.

Dermatophytosis: the management of fungal infections

Dermatophytosis is an infection of the hair, skin, or nails caused by a dermatophyte, which is most commonly of the Trichophyton genus and less commonly of the Microsporum or Epidermophyton genera. Tinea capitis, tinea pedis, and onychomycosis are common dermatologic diseases that may result from such an infection. The treatment of fungal infections caused by a dermatophyte has been successful when treated with oral or topical antifungal agents. Terbinafine, itraconazole, and fluconazole are oral antimycotics that are effective in the treatment of superficial mycoses, although, depending on the severity of the infection, a topical antifungal may be sufficient.

Training Room Management of Medical Conditions: Sports Dermatology

Athletes' skin is subject to a distinct array of physical and environmental stressors. Trauma, the elements, and pathogenic organisms constantly challenge the skin's integrity. This article intends to arm the clinician with a fundamental knowledge of infections, mechanical injuries, and environmental insults common to the skin of athletes. Photographs corresponding to the described entities are included as figures. Because rapid return to play is the ultimate goal after injury or illness, there is a section dedicated to play restrictions as set forth by the National Collegiate Athletic Association. Although the evaluation and management of cutaneous disease is a challenging endeavor, a consistent and systematic approach to this most accessible organ can result in early diagnosis, appropriate treatment, and ultimate performance.

The systemic treatment of onychomycosis

The systemic treatment of fungal infections has changed considerably over the past 10 to 20 years. Though griseofulvin was introduced in the late 1950s and was at the time the only Food and Drug Administration (FDA)-approved drug in the United States for the systemic treatment of onychomycosis, its cure rate seldom exceeds 40%. Newer drugs appear to be reducing treatment times, improving cure rates with a minimum of side effects, and achieving long-term remissions in recalcitrant infections. Itraconazole was FDA approved in 1995, and terbinafine was FDA approved in 1996. Both have been used safely for many years, demonstrating efficacy in short-term treatment with a low incidence of side effects. Fluconazole, though not yet FDA approved for onychomycosis, has also shown efficacy in many situations. Direct-to-the-public advertising has raised interest in patients to seek treatment. There are also some new investigational drugs for fungal infections that may augment or supplant current therapy.

Itraconazole in the treatment of tinea capitis caused by Microsporum canis: experience in a large cohort

Mycotic scalp infection caused by Microsporum canis is one of the more recalcitrant disorders, with increasing incidence during the last decade. We report our experience with administration of itraconazole in 163 children (86 girls, 77 boys) with M. canis tinea capitis. Fifty-five patients had previous treatment with terbinafine without success. In all children, the dosage of itraconazole was adjusted according to body weight, with 5 mg/kg/day given in a continuous regimen either as a capsule (116 patients) or an oral suspension (47 patients). In all children, there was both clinical and mycologic cure after a mean treatment period of 39 +/- 12 days (range 10-77 days). Eleven children (6.7%) had side effects: diarrhea in five children, cutaneous eruption in four, and abdominal pain in two. Itraconazole was effective and safe for the treatment of M. canis tinea capitis.

Treatment of Microsporum spp. tinea capitis with pulsed oral terbinafine

Oral terbinafine is widely used in the treatment of superficial dermatomycoses as well as subcutaneous and systemic mycoses. It is also useful in treating tinea capitis, although for Microsporum canis and some ectothrix organisms, the effectiveness of the drug may be less than for some endothrix infections. In this study, we undertook a double-blind randomized trial comparing standard and double doses of terbinafine given in a pulsed protocol (1 week on, 3 weeks off) in treating Microsporum spp. tinea capitis in 42 individuals. We found that pulsed terbinafine at a higher dose did not improve treatment efficacy. However, our data clearly demonstrated that the duration of treatment is an important factor in determining clinical outcome and cure. Two pulses of standard dose terbinafine were found to be sufficient for treating most cases of Microsporum spp. tinea capitis, although additional treatment (a third pulse) may be needed if clinical improvement is not evident at 8 weeks after initiating therapy.

Serum Sickness–Like Reaction Associated with Griseofulvin

OBJECTIVE

To describe a serum sickness—like reaction associated with griseofulvin in a child being treated for tinea capitis.

CASE SUMMARY

A previously healthy 5-year-old boy presented with tactile fever, rash on his legs and back, swelling of his toes and fingers, and leg pain. He was being treated at the time with griseofulvin for tinea capitis. Laboratory evaluation including immunologic workup revealed no abnormalities. Replacement of griseofulvin with itraconazole, along with an antihistamine and a nonsteroidal antiinflammatory drug, led to complete resolution of the patient's symptoms. An objective causality assessment revealed that the adverse reaction was probable.

DISCUSSION

Serum sickness—like reactions may occur 7–21 days following exposure to an offending agent. Clinical manifestations are similar to those of serum sickness, with fever, malaise, and cutaneous eruption. However, on laboratory workup, complement levels are normal. Management of serum sickness—like reaction includes replacing the offending agent and providing symptomatic relief.

CONCLUSIONS

Clinicians should be aware of the possibility of serum sickness—like reaction associated with griseofulvin therapy and consider the possibility when choosing between griseofulvin and newer, more expensive drugs.

Surgical treatment of tinea capitis in childhood

Fungal infections of the scalp can cause kerion, pus-filled swellings, that may look like bacterial abscesses. We report on two children who underwent incision and drainage of their kerions under local and general anesthesia. This treatment was inappropriate: it carried the risk associated with general anesthesia and surgery without providing the therapeutic chance linked to adequate antimicrobial chemotherapy. We recommend that children who are present at emergency departments with pus-filled swellings on the scalp should be referred to a dermatology unit where appropriate clinical and laboratory investigations and antifungal treatment can be provided, if considered adequate.

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 itraconazole's 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.

The use of fluconazole to treat superficial fungal infections in children

Fluconazole has excellent absorption and good persistence in tissues that suggests it may be useful in superficial fungal infections. The predominant use in pediatric superficial fungal infection has been for tinea capitis, and successful treatment has been shown with both daily and weekly fluconazole regimens. The data regarding fluconazole use in superficial fungal infections in children are somewhat limited; however, it seems that there is good potential for the safe use of fluconazole to treat tinea capitis in children. Further studies need to be conducted, particularly in cases of tinea capitis (both T. tonsurans and M. canis), to determine the optimal treatment regimens using fluconazole.

Tinea capitis: epidemiology, diagnosis and management strategies

Tinea capitis is a common superficial fungal infection of the scalp in children, particularly in those of African descent. Trichophyton tonsuran, an anthropophilic dermatophyte, is responsible for the majority of cases in North America. The clinical presentations are variable and include: (i) a "seborrheic" form that is scaling, often without noticeable hair loss; (ii) a pustular, crusted pattern, either localized or more diffuse; (iii) a "black dot" variety characterized by small black dots within areas of alopecia; (iv) a kerion, which is an inflammatory mass; and (v) a scaly, annular patch. Most experts still consider griseofulvin to be the drug of choice, but recommend a higher dosage of 20-25 mg/kg/day for 8 weeks because of the increase in treatment failures. Despite a history of having an excellent tolerability profile, the long treatment course and higher doses required for griseofulvin have led to consideration of new antifungal agents for this infection. Terbinafine, itraconazole, and fluconazole compartmentalize in skin, hair, and nails, thereby allowing shorter treatment courses of < or =4 weeks. All have generally been shown to be effective in the treatment of tinea capitis and appear relatively well tolerated, with gastrointestinal symptoms being the most common adverse effect. Monitoring for liver enzyme elevations is generally unnecessary if therapy is limited to </=4 weeks. As more data regarding efficacy, tolerability, and dose administration becomes available, one or more of these new antifungal agents may become first-line therapy for tinea capitis. For now, we recommend their use in cases of treatment failure or recurrent noncompliance. Our personal preference in the younger child is fluconazole. It has a favorable tolerability profile and is available in liquid form. In the older child who can take a tablet, terbinafine is recommended. More data is available on this drug in the treatment of tinea capitis than the other two, and it is the least expensive. Although the oral antifungal agents are the most important aspect of therapy, adjunctive therapy may be beneficial. Sporicidal shampoos, such as selenium sulfide, can aid in removing adherent scales and hasten the eradication of viable spores from the scalp in the hope of decreasing the spread of this infection. The use of corticosteroids for the treatment of kerions is controversial. Many of the studies have design flaws or show variable results. We recommend either a short burst of oral corticosteroids or topical corticosteroids in patients with the most severe disease.

Ketoconazole potentiates the antitumor effects of nocodazole: In vivo therapy for human tumor xenografts in nude mice

Our previous studies demonstrated that the oral antifungal agent ketoconazole (KT) induces apoptosis and G0/G1 phase cell cycle arrest in human cancer cell lines. In this study, we first demonstrated that KT (1 microM) potentiated the apoptotic effects of nocodazole (ND, 1 nM) in COLO 205 cancer cells. We further demonstrated the therapeutic efficacy of a combined treatment of KT (50 mg/kg/three times per week) and ND (5 mg/kg/three times per week) in vivo by treating athymic mice bearing COLO 205 tumor xenografts. The antitumor effects of ND were significantly potentiated by KT in mice after 6 wk of treatment. No gross signs of toxicity were observed in mice receiving these treatment regimens. The apoptotic cells were detected in a microscopic view of the terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling staining and by observation of DNA fragmentation in KT + ND-treated tumor tissues. The levels of cell cycle regulatory proteins were determined by Western blot analysis. Treatment with KT inhibits tumor growth through elevation of p53, p21/CIP1, and p27/KIP1 as well as inhibition of cyclin D3 and cyclin-dependent kinase 4 protein expression. Immunohistochemical staining analysis showed that p53, p21/CIP1, and p27/KIP1 immunoreactivity were induced in the tumor tissues. To clarify the roles of the p21/CIP1 and p27/KIP1 protein expression involved in G(0)/G(1) arrest and/or apoptosis induced by a combined treatment with KT and ND, antisense oligodeoxynucleotides (ODNs) specific to p21/CIP1 and p27/KIP1 were used. Our results demonstrated that apoptotic phenomena, including BAX induction and cytochrome C released from mitochondria induced by KT + ND, were significantly attenuated by pretreatment the cells with the p27/KIP1-specific antisense ODNs. These results indicate that p27/KIP1 protein does indeed play a critical role in the KT + ND-induced apoptosis. Our study revealed the molecular mechanism of KT + ND in regression of the tumor growth. The apoptotic effects of KT in a great variety of cancer cells make it a very attractive agent for cancer chemotherapy.

Tinea capitis due to Trichophyton rubrum in a neonate

Tinea capitis is a common infection of school-aged children, but there have been only a few reports of tinea capitis in newborns. Furthermore, Trichophyton rubrum as a causative organism of tinea capitis is documented very rarely. We report herein a neonate in whom T. rubrum was the causative agent. This boy was successfully treated with three pulses of oral itraconazole solution.

Tinea capitis in schoolchildren from lvory Coast (western Africa). A 1998-1999 cross-sectional study

BACKGROUND

Tinea capitis is a worldwide public health problem that poses specific therapeutic challenges. This dermatophytosis of the scalp is endemic in Africa. The objectives of this study were to determine the prevalence, the associated demographic factors, causative species, and clinical types of tinea capitis in Abidjan, Ivory Coast.

METHODS

From June 1998 to March 1999, 1913 children aged between 4 and 15 years, and schooling in seven urban primary schools of Abidjan (Ivory Coast), were examined clinically for tinea capitis. Among all children showing symptoms suggestive of scalp ringworm, hair stumps and scales were collected and exposed to direct microscopic examination using 30% potassium hydroxide solution, and cultivation on Sabouraud's dextrose agar with or without actidione.

RESULTS

Among 227 symptomatic children, cultures positive for fungi were found in 217, yielding an overall tinea capitis prevalence of 11.34% [95% Confidence Interval (CI), 9.97-12.85]. By univariate analysis, tinea capitis was significantly associated with boys [odds ratio (OR) 7.85; CI 5.22-11.81] and in children belonging to the intermediate 8-11 years age group (OR 1.93; CI 1.29-2.90). Trichophyton soudanense and Microsporum langeronii were the most prevalent etiologic agents (63.6% and 31.3%, respectively), whereas a mixture of both T. soudanense and M. langeronii was observed in a 2.8% proportion. Finally, 2.3% of isolated species were represented by T. violaceum.

CONCLUSIONS

Our survey provided evidence that tinea capitis is endemic in Ivory Coast, constituting a substantial infectious dermatological disturbance. T. soudanense was the most frequent causative agent, whereas T. violaceum was isolated for the first time in this sub-Saharan western African country.

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.

Cluster analysis of human and animal pathogenic Microsporum species and their teleomorphic states, Arthroderma species, based on the DNA sequences of nuclear ribosomal internal transcribed spacer 1

We performed a cluster analysis of human and animal pathogenic Microsporum species and their teleomorphic states, Arthroderma species, including A. otae-related species (M. canis, M. audouinii, M. distortum, M. equinum, M. langeronii, and M. ferrugineum) and M. gypseum complex (A. fulvum, A. gypseum, and A. incurvatum) using DNA sequences of nuclear ribosomal internal transcribed spacer 1 (ITS1). The dendrogram showed the members of A. otae-related species to be monophyletic and to construct an extremely closely related cluster with a long horizontal branch. This ITS1-homologous group of A. otae was organized in 6 unique genotypes, while sequences of the members of the ITS1-homologous group of M. gypseum complex are more diverse. This ITS1-based database of Microsporum species and their teleomorphic states will provide a useful and reliable species identification system: it is time-saving (takes two to three days), accurate and applicable even to strains with atypical morphological features or in a non-culturable state.

Therapeutic options for the treatment of tinea capitis caused by Trichophyton species: griseofulvin versus the new oral antifungal agents, terbinafine, itraconazole, and fluconazole

Tinea capitis is a relatively common fungal infection of childhood. Griseofulvin has been the mainstay of management. However, newer oral antifungal agents are being used more frequently. A multicenter, prospective, randomized, single-blinded, non-industry-sponsored study was conducted in centers in Canada and South Africa to determine the relative efficacy and safety of griseofulvin, terbinafine, itraconazole, and fluconazole in the treatment of tinea capitis caused by Trichophyton species. The regimens for treating tinea capitis were griseofulvin microsize 20 mg/kg/day x 6 weeks, terbinafine [> 40 kg, one 250 mg tablet; 20-40 kg, 125 mg (half of a 250 mg tablet); < 20 kg, 62.5 mg (one-quarter of a 250 mg tablet)] x 2-3 weeks, itraconazole 5 mg/kg/day x 2-3 weeks, and fluconazole 6 mg/kg/day x 2-3 weeks. Patients were asked to return at weeks 4, 8, and 12 from the start of the study. Griseofulvin was administered for 6 weeks and the final evaluation was at week 12. Terbinafine, itraconazole, and fluconazole were administered for 2 weeks and the patient evaluated 4 weeks from the start of therapy. At this time, if clinically indicated, one extra week of therapy was given. There were 200 patients randomized to four treatment groups (50 in each group). At the final evaluation at week 12, the number of evaluable patients were griseofulvin, 46; terbinafine, 48; itraconazole, 46; and fluconazole, 46. Patients who discontinued therapy or were lost to follow-up were griseofulvin, 1/3; itraconazole, 0/4; terbinafine, 0/4; and fluconazole, 0/4. The causative organisms were Trichophyton tonsurans and T. violaceum species. Patients were regarded as effectively treated at week 12 if there was mycologic cure and either clinical cure or only a few residual symptoms. Effective treatment was recorded in, intention to treat, griseofulvin (46 of 50, 92.0%), terbinafine (47 of 50, 94.0%), itraconazole (43 of 50, 86.0%), and fluconazole (42 of 50, 84.0%) (p=0.33). Adverse effects were reported only in the griseofulvin group (gastrointestinal effects in six patients). Discontinuation from therapy due to adverse effects occurred only in the griseofulvin group (nausea in one patient). For the treatment of tinea capitis caused by the Trichophyton species, in this study, griseofulvin given for 6 weeks is similar in efficacy to terbinafine, itraconazole, and fluconazole given for 2-3 weeks. Each of the agents has a favorable adverse-effects profile.

Doubled dose of oral terbinafine is required for Microsporum canis tinea capitis

Fourteen children, ages 1-15 years, with Microsporum canis tinea capitis were given oral terbinafine for 4 weeks at the recommended daily dose according to their weight: 10-20 kg, 62.5 mg; 20-40 kg, 125 mg; > 40 kg, 250 mg. Because none of the patients had clinically responded to treatment by week 4 the dose of terbinafine was doubled (up to 250 mg) for an additional 4-8 weeks in six patients, and continued at the original dose in six patients. Two patients dropped out of the study. On final evaluation, four patients were cured after 8-12 weeks of treatment. All cured patients received the doubled dose of terbinafine, except for one who was on the usual adult dose of 250 mg from the onset. Oral terbinafine was well tolerated by all but one patient, who experienced gastrointestinal disturbance and slightly raised transaminase levels during the first 4 weeks of treatment. Terbinafine side effects were not correlated with dosage or duration of treatment. We conclude that oral terbinafine should be dosed for M. canis tinea capitis at a revised schedule according to body weight: 10-25 kg, 125 mg/day and > 25 kg, 250 mg/day. The appropriate duration of terbinafine treatment remains to be determined.

Ketoconazole induces G0/G1 arrest in human colorectal and hepatocellular carcinoma cell lines

Ketoconazole is an oral-antifungal agent that has been used worldwide in the treatment of some hormone-dependent human cancer. In this study, we demonstrated that ketoconazole (20 microM) induced various types of human cancer cell growth arrest in the G0/G1 phase. Our results revealed that ketoconazole-induced growth arrest was more profound in COLO 205 and Hep G2 (with wild-type p53) than in HT 29 (p53 His(273) mutant) and Hep 3B (with deleted p53) cells. The protein levels of p53, p21/Cip1, and p27/Kip1 were significantly elevated by ketoconazole (10 microM) treatment in COLO 205 but not in HT 29 cells. The ketoconazole-induced G0/G1 phase arrest in COLO 205 cells was attenuated by p53-specific antisense oligodeoxynucleotides (20 microM) treatment. These results suggested that the p53-associated signaling pathway is involved in the regulation of ketoconazole-induced cancer cell growth arrest. By Western blot analysis, we demonstrated that cyclin D3 and CDK4 protein but not other G0/G1 phase regulatory protein levels were decreased by ketoconazole-treatment in both COLO 205 and HT 29 cells. Our study provides the basis of molecular mechanisms for ketoconazole in growth inhibition of human cancer cells and such results may have significant applications for cancer chemotherapy.

Optimizing the therapeutic approach in tinea capitis of childhood with itraconazole

BACKGROUND

Tinea capitis is the most common dermatophytosis of childhood with increasing incidence. Whereas griseofulvin is considered by many as the mainstay of treatment, newer oral antifungal agents, including fluconazole, itraconazole and terbinafine have demonstrated higher efficacy, resulting in shorter treatment durations.

OBJECTIVES

We aimed to determine the optimum regimen for the treatment of childhood tinea capitis with itraconazole.

METHODS

A mycological culture outcome-dependent combination of a 28-day continuous and facultative additional 14-day courses with itraconazole was used in 42 children (20 girls; 22 boys) aged 12-140 months (mean 66) with tinea capitis due to Microsporum canis (n = 26) and Trichophyton violaceum (n = 16). The drug was given orally according to the patients' body weight (50 mg daily for < 20 kg; 100 mg daily for > or = 20 kg) over 4 weeks. Direct microscopy and fungal culture as a parameter for efficacy were repeated 2 weeks after termination of treatment. Assessment of efficacy was based on the evaluation of results from light microscopy and culture at 8 weeks after initiation of treatment, and in the case of a further positive mycological culture at 14 and 20 weeks, respectively. A positive fungal culture at these times resulted in an additional course for 2 weeks with the initially chosen itraconazole dosage.

RESULTS

In 34 of 42 patients a single 4-week course of itraconazole resulted in a complete mycological cure of lesions as demonstrated by light microscopy and mycological culture. Four of 42 patients had to be treated by a second itraconazole course for 2 weeks, and four children received a third course of itraconazole for 2 weeks until all lesions showed negative direct microscopy and mycological culture. No abnormal haematological or biochemical results occurred. Apart from transient, completely reversible indigestion in two children, no side-effects were observed.

CONCLUSIONS

A culture-based 28-day continuous therapeutic regimen plus facultative cultural outcome-dependent additional 14-day courses of a body weight-adapted dosage of itraconazole in tinea capitis due to M. canis and T. violaceum is discussed; this offers the advantage of an effective therapy with complete negative direct microscopy as well as negative cultural results, within a shorter active treatment period (cf. previous studies with continuous administration of itraconazole).