Systemic drugs in the treatment of dermatophytoses

A double-blind randomized comparative trial: eberconazole 1% cream versus clotrimazole 1% cream twice daily in Candida and dermatophyte skin infections

In a double-blind phase III study the efficacy and tolerance of eberconazole 1% cream was compared with clotrimazole 1% cream, applied twice daily for four consecutive weeks in 157 patients, with mycologically proven cutaneous candidosis (24 patients, 25 infected sites) and in 133 patients with dermatophyte skin infections (141 treated sites). The analysis was carried out by number of infected and treated sites. The four groups of sites and the distribution of target lesions were similar. The distribution of the sum of clinical scores and infecting organisms were also similar. There were no differences between the groups in terms of the range and mean duration of infection. At the end of therapy and on follow-up in skin candidosis the proportion of patients with effective treatment was 73 and 50% for clotrimazole and eberconazole, respectively. Premature termination due to adverse effects was 26.7% for clotrimazole and 20% for eberconazole. At the end of treatment of dermatophyte infections the proportion of patients with effective treatment was 46% for clotrimazole and 61% for eberconazole. At the overall assessment (6 weeks after the end of treatment) eberconazole was judged effective in 72% of treated sites, whereas clotrimazole was effective in 61%, this difference was not statistically significant (P = 0.15). There were three relapses (4%) in the clotrimazole-treated group and one relapse (1%) in the eberconazole group. One patient treated with eberconazole cream (1%) had a premature termination due to adverse events attributable to the medication.

Antifungal activity of magnolol and honokiol

Two neolignan compounds, magnolol (5,5'-diallyl-2,2'-dihydroxybiphenyl, 1) and honokiol (5,5'-diallyl-2,4'-dihydroxybiphenyl, 2), were isolated from the stem bark of Magnolia obovata and evaluated for antifungal activity against various human pathogenic fungi. Compound 1 and 2 showed significant inhibitory activities against Trichophyton mentagrophytes, Microsporium gypseum, Epidermophyton floccosum, Aspergillus niger, Cryptococcus neoformans, and Candida albicans with minimum inhibitory concentrations (MIC) in a range of 25-100 microg/ml. Therefore, compound 1 and 2 could be used as lead compounds for the development of novel antifungal agents.

Oral ketoconazole in cutaneous fungal infections

Few data are available on the mechanism by which oral ketoconazole reaches the stratum corneum and exhibits its antifungal activity. The rapid onset of effect and the isolation of ketoconazole from the sweat support the theory that this agent reaches its site of action through eccrine sweat secretion. However, passive diffusion from the bloodstream and sebum secretion may also account for the antimycotic effect at the level of the stratum corneum. Oral ketoconazole has been shown to be effective in a variety of cutaneous fungal infections. However, systemic antifungal therapy is best reserved for extensive infections or those resistant to topical therapy.

Childhood white superficial onychomycosis caused by Trichophyton rubrum: report of seven cases and review of the literature

BACKGROUND

Although white superficial onychomycosis (WSO) is well recognized in adults and considered to be mainly caused by Trichophyton mentagrophytes, childhood WSO is rare. WSO caused by Trichophyton rubrum in prepubertal children has never been reported.

OBJECTIVE

Our purpose was to describe the existence of WSO in children and to emphasize that T. rubrum may be its main cause.

METHODS

Seven children with WSO seen between 1988 and 1993 were examined. Only patients who had a positive potassium hydroxide preparation and a positive fungal culture were included.

RESULTS

Seven healthy prepubertal children, 2 to 9 years of age, were identified with WSO. All cases were proved to be caused by T. rubrum. Six patients had associated tinea pedis, and five had a family history of tinea pedis. Topical antifungal therapy was partially effective in some cases.

CONCLUSION

This report documents the existence of WSO in prepubertal children. All cultures grew T. rubrum. Although onychomycosis is not as common in prepubertal children as in adults, it may be underrecognized.

Topical treatment of tinea corporis and tinea cruris with eberconazole (WAS 2160) cream 1% and 2%: a phase II dose-finding pilot study

In a phase II pilot dose-finding study 60 patients with mycologically proven tinea corporis and tinea cruris were treated with eberconazole cream 1% once daily (group A, 15 patients), 1% twice daily (group B, 15 patients), 2% once daily (group C, 15 patients) or 2% twice daily (group D, 15 patients). Treatment was continued for 2 weeks after clinical cure; the maximum duration of treatment was limited to 6 weeks. The characteristics of the four groups of patients, distribution of the target lesions, clinical sum of baseline scores and infecting organisms were similar. Statistical examination showed that the mean time of appearance in weeks of negative microscopy and culture was similar in the four groups. There was no significant difference between the groups in terms of the range and mean duration of treatment. By the end of the study, treatment was effective in 13 patients (87%) in group A, 14 (93%) in group B and 11 (73%) in both groups C and D (mycological cure and clinical cure or residual minimal signs and symptoms). One patient in group A did not respond to treatment and two patients in group C had to withdraw because of side-effects. No undesirable effects or significant changes were seen in the blood tests. At the assessment 6 weeks post therapy, eberconazole was judged to have been effective in 93% of patients in group A, 100% of patients in groups B and D and 61% of patients in group C. Although not statistically significant, a trend towards more favourable results was seen in group B when considering the mean time of appearance of clinical cure and negative KOH and culture.

Management of common superficial fungal infections in patients with AIDS

Cutaneous fungal infections are a major source of morbidity in HIV-infected patients, and their management poses special challenges. Superficial mycoses, such as tinea pedis, tinea cruris, tinea corporis, and onychomycosis, are no more common in HIV-infected patients than in the HIV-negative population but are of greater severity. Although they respond to topical and systemic antifungal agents, HIV-positive patients are predisposed to frequent recurrences. Unusual types of fungal infections such as Majocchi's granuloma are more likely to develop in HIV-infected patients and respond best to systemic antifungal therapy with imidazoles or triazoles. Infections with Candida albicans develop in virtually all HIV-positive patients. Although mucosal involvement is the most common, patients may also develop superficial cutaneous infections. Topical agents are frequently all that is necessary, but in some, oral medications are required. Although fluconazole is effective, an appreciable number of isolates are resistant. Patients with pityriasis versicolor and seborrheic dermatitis, in which Pityrosporum species are thought to be involved, respond well to short courses of oral ketoconazole. Milder forms of seborrheic dermatitis can also be treated with low-potency topical steroids or topical ketoconazole. The oral triazole fluconazole is not particularly effective in the management of seborrheic dermatitis. Although the cause of eosinophilic pustular folliculitis, a common disorder in immunosuppressed HIV-positive patients, is unknown, some can be cured with high doses of itraconazole, suggesting that fungi are important in the pathogenesis of the disease in some patients.

Onychomycosis in children

BACKGROUND

Onychomycosis is the most common nail disease in adults. During recent years an increase in its frequency has been reported in children.

MATERIALS AND METHODS

Children under 12 years were examined and a clinical diagnosis of onychomycosis was made (Figs. 1-4). Potassium hydroxide (KOH) preparations were made and a fungus culture was done in each case.

RESULTS

Twenty-six children with onychomycosis are reported; 16 boys (61.4%) and 10 girls (38.6%). The average age was 8 years. The most frequent variety was distal subungual onychomycosis (88.5%) and the earliest sign was distal subungual hyperkeratosis. The agent most frequently isolated was Trichophyton rubrum which was found in 18 cases (69.2%).

CONCLUSIONS

Onychomycosis in children is not exceptional. Attention should be given to any sign during physical examination to avoid dystrophy of the nails and also to eliminate any source of infection.