Efficacy and safety of adapalene gel as a reactive treatment for cetuximab-induced skin toxicity in recurrent or metastatic squamous cell carcinoma of the head and neck: A historical cohort comparison study

INTRODUCTION

Despite the common occurrence of cetuximab (Cmab)-induced skin toxicity, management strategies are not well established. The traditional mainstay method consists of topical steroids, which, if used excessively, may give rise to other concerns. Alternatively, adapalene can activate epidermal growth factor receptor pathways to potentially alleviate these toxicities.

METHODS

We prospectively studied 31 patients with recurrent or metastatic squamous cell carcinoma of the head and neck (R/M SCCHN) who were eligible to use adapalene gel as a reactive treatment for topical steroid-refractory skin toxicity. For comparison, we retrospectively reviewed 99 patients with R/M SCCHN (historical control cohort) whose skin toxicity was mainly treated with topical steroids. We compared the frequency and severity of Cmab-induced skin toxicity, Cmab therapy status (e.g., dose modification), side effects caused by topical steroids and adapalene gel itself, and other medical interventions.

RESULTS

Adapalene gel was used by eight patients (25.8%) in the prospective cohort. Patients in the historical control cohort more frequently required escalation of topical steroid potency (34.3% vs. 12.9%, p = 0.022). Although there was no statistically significant difference in the frequency of grade ≥3 facial skin rash and paronychia between the two cohorts, the prospective cohort showed a significantly shorter time to complete recovery from grade 2/3 paronychia (16 vs. 47 days, p = 0.017). Further, while no skin infections were observed in the prospective cohort, 13 patients in the historical control cohort developed skin infections, especially periungual infection (0% vs. 13.1%, p = 0.024). In addition, no patients in the prospective cohort received a dose reduction of Cmab due to skin toxicities, compared to 20 patients in the historical control cohort (0% vs. 20.2%, p = 0.003). No apparent adapalene gel-related side effects were observed.

CONCLUSIONS

Adapalene gel may be an effective management option for topical steroid-refractory Cmab-induced skin toxicities and could improve compliance with Cmab therapy.

Combination of available topical beta-blockers and antibiotic ointment for epidermal growth factor receptor tyrosine kinase inhibitor-induced paronychia and pseudopyogenic granulomas in Taiwan

BACKGROUND

Painful paronychia and pseudopyogenic granuloma (PG) are common adverse drug reactions (ADRs) associated with the use of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) to treat non-small cell lung cancer (NSCLC). Multiple local management approaches have been tested with unsatisfactory results. We have introduced an occlusion therapy technique through which available topical drugs for longer than 2 years.

METHODS

Based on the cancer registry and case management system of our hospital, from July 2019 to July 2020, we retrospectively enrolled patients with NSCLC who were treated with EGFR-TKIs and received applications of 0.5% timolol ophthalmic solution (TIMOPTOL XE 0.5%®) combined with a neomycin/tyrothricin ointment (Biomycin®) using the occlusion method to treat paronychia or PG.

RESULTS

A total of 22 patients were enrolled, with a mean age of 66.5 years, most of whom were women (72.7%). Periungual lesion-related pain was reported by all patients, and periungual bleeding and PG were reported in 14% (3/22) and 64% (14/22) of patients, respectively. After the occlusion therapy application of timolol ophthalmic solution combined with neomycin/tyrothricin ointment twice daily, the overall response rate was 83.3%, including complete response in 18% (4/22) of cases and partial response in 68% (15/22) of cases.

CONCLUSION

We presented an occlusion method using available topical beta-blockers and antibiotic ointment for EGFR-TKI-induced paronychia and PG in Taiwan. The result is favorable. Further randomized control trial is urgent to validate our findings.

Atypical paronychia: don't forget herpesvirus

Paronychia is usually caused by bacterial infections. Herpetic whitlow is an acute infection of the fingers or toes caused by herpes simplex viruses and it typically presents with vesicles. We report the case of a 78-year-old woman with gingivostomatitis and atypical paronychia in several fingers without blisters.

You're the Flight Surgeon

Warneke J, Pavelites J. You're the flight surgeon: tularemia. Aerosp Med Hum Perform. 2020; 91(5):379-381.

Are topical beta-blockers really effective "in real life" for targeted therapy-induced paronychia

Paronychia and periungual pyogenic granuloma represent one of the most common and bothersome dermatologic toxicities observed with ErbB inhibitors. There is no standardized treatment, and management remains challenging. Moreover, conservative management with noninvasive treatment should be promoted for fragile patients in a metastatic setting. Over the last few years, the efficacy of topical blocking agents has been considered for managing cutaneous or mucosal pyogenic granulomas. Very recently, the use of topical propranolol or of timolol has been reported in several patients undergoing treatment with EGFR inhibitors and developing pyogenic granulomas of the nail. We performed a retrospective single-center review of patients with targeted therapy-related paronychia/periungual pyogenic granulomas who had been treated with topical timolol, either alone or in combination with other topical treatments. Nearly two thirds of patients showed at least a partial response after 1 month of therapy, and the use of a topical beta-blocker in our population was associated with a favorable safety profile. Finally, topical timolol may represent a promising treatment option for the management of cancer patients suffering from painful periungual lesions. Comparative clinical trials, however, are still needed.

Imiquimod-induced hypopigmentation following treatment of periungual verruca vulgaris

Imiquimod is a topical immunomodulating medication approved by the US Food and Drug Administration for the treatment of condyloma acuminata, actinic keratoses (AKs), and superficial basal cell carcinoma (BCC). Imiquimod commonly is used off label for its antiviral and antitumoral effects. We present a case of a 51-year-old man with vitiligolike depigmentation following treatment of periungual verruca vulgaris with imiquimod therapy.

Clinical impact of minocycline on afatinib-related rash in patients with non-small cell lung cancer harboring epidermal growth factor receptor mutations

BACKGROUND

The management of skin toxicity is crucial for efficient afatinib treatment, but the role of tetracycline class antibiotics (TCs) in managing these rashes is relatively unknown.

METHODS

We reviewed the clinical records of patients who were administered afatinib for the treatment of non-small cell lung cancer harboring epidermal growth factor receptor mutations between October 2014 and November 2016. Twenty-five patients, who received TCs for the management of afatinib-related skin disorders, were enrolled.

RESULTS

Minocycline was administered orally to participants. Afatinib-related toxic effects, such as rash, diarrhea, and paronychia, were observed in 92%, 92%, and 40% of cases, respectively. Although 24% of diarrhea and 4% of paronychia cases were rated grade 3 or higher, no severe cases of rash were observed during afatinib treatment. Of the 18 afatinib dose reductions, 14 (78%), three (17%), and one (6%) resulted from diarrhea, paronychia, and stomatitis, respectively; no patients required a dose reduction because of rash. When minocycline treatment started, 21 patients (84%) had a rash of grade 1 or less, and three patients had a grade 2 rash. A response to afatinib was observed in 18 patients (72%) and the median duration of afatinib administration was 501 days. An adverse event related to minocycline (grade 1 nausea) was observed in one patient.

CONCLUSIONS

A large proportion of the study patients started minocycline before grade 2 rash development and the severity of afatinib-related rash was lower than that previously reported. Oral TCs may be beneficial, especially if started early.

Clindamycin-induced acute generalised exanthematous pustulosis: five cases and a review of the literature

Acute generalised exanthematous pustulosis (AGEP) is a rare but serious cutaneous adverse drug reaction, often related to antibiotics such as beta-lactams or macrolides. However, it is rarely associated with clindamycin which belongs to the lincosamide antibiotics. The Netherlands Pharmacovigilance Centre Lareb received five reports of AGEP associated with the use of clindamycin. We present these five cases and provide support for this association from the Lareb database, the database of the WHO Collaborating Centre for International Drug Monitoring (Vigibase™), the database of the European Medicine Agency (Eudravigilance), and from a mini review of the literature.

Paronychia-like cutaneous leishmaniasis

Chronic paronychia is an inflammatory recalcitrant disorder affecting the nail folds. We report one patient with paronychia revealing ungueal leishmaniasis. A 34-year-old man, resident in the north of Morocco, presented with a 6-month history of an inflamed proximal nail fold of the left thumb, resistant to antibiotics and anti-fungal treatments. En bloc excision of the proximal nail fold was done. The histopathological exam showed epithelioid granulomas with giant cells and the presence of leshmania amastigotes, leading to the diagnosis of ungueal leishmaniasis. Clinical aspects of cutaneous leishmaniasis can be very misleading. The paronychial form is rarely described. In endemic areas it is necessary for the physician to be aware of atypical skin presentations of leishmaniasis.

Treatment and prevention of paronychia using a new combination of topicals: report of 30 cases

AIM

Moderate and chronic paronychia is a common disease affecting the hand. Treatment can be effective but the affection is often recurrent, especially as an occupational disease. Moreover, this condition may be complicated by a Candida spp or by bacterial infections. Therefore, general preventive measures can be useful in maintaining health. The aim of this study was to investigate the efficacy and tolerability of a new combination of topical medications in the treatment and prevention of moderate and chronic paronychia. This formulation includes an insulating polymer (Syn-cell barrier), two topical antifungals (octopirox and climbazole) and a molecule with anti-inflammatory activity (corticoid-like repair).

METHODS

Thirty adult subjects (age, 16-78 years; 24 females and 6 males) affected by moderate or chronic paronychia, with or without nail alterations, were evaluated. Included in the study were patients with allergic contact dermatitis (8), irritant contact dermatitis (19), psoriatic paronychia (2 patients), lichen planus of the nails (1 patient). Sometimes Candida spp or bacteria overlapped with paronychia (16 patients positive for Candida spp and 4 patients with bacterial paronychia), sometimes infectious paronychia was not associated with dermatitis of the hands. All 30 subjects were treated with a new cream formulation, three applications per day for 2 months. In 8 patients with proven and severe candidiasis of the nails, oral fluconazole 100 mg was added for 20 days. All patients with bacterial perionyxis took clarithromycin 500 mg twice daily for six days. Patients were then followed for 8 weeks.

RESULTS

After two months of treatment, 26 patients responded to therapy. In particular, the treatment evaluation at the end of the follow-up period showed a clinical cure in 46.6% (14 patients), improvement in 40% (12 patients), and failure in 13.4% (4 patients). There was a side effect (moderate skin irritation) in 2 patients, but the drug was not discontinued.

CONCLUSION

Results of the present study, based on its safety, effectiveness and innovative features, indicate that this combination of topical cream may be considered as a new alternative for treatment and prevention of paronychia, especially in case of occupational hand disease where prolonged treatment and continuous prevention are needed.

[Exudative onycholysis and acute bacterial paronychia related to BIBF-1120 and paclitaxel: response to topical therapy]

A case of a 50 years-old breast cancer patient treated with weekly paclitaxel and BIBF 1120 is reported herein. At the end of the twelfth cycle of chemotherapy, the patient developed distal onycholysis with intense hyponychium serous exudates, pain and malodor in all her fingernails. It was treated with topical fusidic acid and 1% methylprednisolone aceponate two times daily, with an excellent clinical response from the first three days of treatment. Bacterial paronychia with nail plate loss of the fifth left fingernail was observed a week after the topical therapy was started, with positive cultures for Methicillin susceptible Staphylococcus aureus. There are few reported cases of exudative onycholysis associated with chemotherapy. However, these are especially related to paclitaxel. No recurrences of nail disturbances were observed weeks after the end of chemotherapy. Topical corticosteroids and fusidic acid could be considered as a therapeutic option when exudative onycholysis related to paclitaxel is established

Cutaneous side-effects of EGFR inhibitors and their management

Epidermal growth factor receptor (EGFR) inhibitors are an increasingly important treatment option for metastasized cancer in patients. In addition to the pivotal role of EGFR in the development and progression of malignant tumors, EGFR is also important for proliferation and differentiation of the human epidermis and hair follicles. As a consequence, cutaneous side-effects are frequently observed during cancer therapy with EGFR inhibitors. During the first few weeks of treatment, acneiform eruptions are the earliest common side-effect. Xerosis and fissures are complications appearing in later treatment phases. Paronychia and alterations in hair growth are less common and generally seen after a longer period of treatment. We present an overview of the various cutaneous side-effects associated with EGFR inhibition and discuss their respective therapeutic options.

Autologous "foreign body" as a sequel of improper cutting of an ingrowing toe nail?

We report on a 63-year-old male who suffered from an ingrown toenail affecting the left first digit for several years. Medical history revealed that repeated vigorous nail plate trimming by the patient relieve the red, painful swelling of his great toe. Furthermore, Emmert onychoplasty as well as non-invasive procedures did not achieve improvement. A thorough surgical exploration of the affected area detected a nail spicule in the deeper paronychium. This was likely caused by improper cutting of the nail plate. Removal of the fragment in combination with partial nail plate excision, followed by phenol cauterization of the matrix resulted in full recovery.

Acute and chronic paronychia

Paronychia is an inflammation of the folds of tissue surrounding the nail of a toe or finger. Paronychia may be classified as either acute or chronic. The main factor associated with the development of acute paronychia is direct or indirect trauma to the cuticle or nail fold. This enables pathogens to inoculate the nail, resulting in infection. Treatment options for acute paronychia include warm compresses; topical antibiotics, with or without corticosteroids; oral antibiotics; or surgical incision and drainage for more severe cases. Chronic paronychia is a multifactorial inflammatory reaction of the proximal nail fold to irritants and allergens. The patient should avoid exposure to contact irritants; treatment of underlying inflammation and infection is recommended, using a combination of a broad-spectrum topical antifungal agent and a corticosteroid. Application of emollient lotions may be beneficial. Topical steroid creams are more effective than systemic antifungals in the treatment of chronic paronychia. In recalcitrant chronic paronychia, en bloc excision of the proximal nail fold is an option. Alternatively, an eponychial marsupialization, with or without nail removal, may be performed.

Primäraffekt am Finger unter dem Bild einer chronischen Paronychie

A 33-year-old woman presented with a 4-months history of a granulating ulcer on the right index finger. Paronychia was suspected and nail extraction with subsequent histopathologic examination of the removed tissue was performed. Two months later, it became known that the patient's sexual partner had been treated for syphilis. The patient's serology was also positive. Subsequent examination of the original tissue sample by polymerase chain reaction, immunohistochemistry using Treponema pallidum-specific antibodies, and silver staining revealed large numbers of syphilis bacteria, confirming the diagnosis of extragenital chancre.

Delirium in an adolescent patient during treatment with cephalexin

Although cephalosporins are generally safe, they have been reported to cause neurotoxic effects in some subjects. We report on a 16-year-old boy with no previous history of psychiatric illness, who developed symptoms of delirium during treatment of paronychia infection with cephalexin. Possible reasons for our patient's particular vulnerability to adverse drug effects in the central nervous system include his young age, a developmental delay, and an earlier head injury.

Chronic paronychia--putting a finger on the evidence

At first glance it seemed a minor problem, but the look on my new patient's face suggested otherwise. His finger had been painful for months and this week it had become worse. His swollen, erythematous nail fold, absent cuticle, and mildly dystrophic nail painted a typical picture of chronic paronychia. Assuming an acute bacterial superinfection, I prescribed a course of antibiotics, but my patient needed advice on treatment of the underlying condition. Another general practitioner had arranged fungal cultures, which had grown candida. Would antifungals be the best treatment? My patient and I agreed to meet in a week to assess his response to the antibiotics and to discuss treatment of the underlying chronic paronychia.

Bacterial Diseases of the Skin

When considering common bacterial diseases of the skin, rather distinct clinical responses to a variety of bacterial infections have been identified. In these cases, it is the specific site of infection and the attendant inflammatory responses that provide the characteristic clinical picture. When the pyoderma extends just below the stratum corneum, it is called impetigo. Nonbullous impetigo is the most common pediatric skin infection. It usually starts in a traumatized area. The typical lesion begins as an erythematous papule, after which it becomes a unilocular vesicle. When the subcorneal vesicle becomes pustular, it ruptures and eventually becomes a yellow, golden crust that is a hallmark of the disease process. Bullous impetigo is a less common form of impetigo, accounting for fewer than 30% of all impetigo cases. It occurs in infants and is characterized by rapid progression of vesicles to the formation of bullae measuring larger than 5 mm in diameter in previously untraumatized skin. Treatment of nonbullous impetigo must include intervention against the pathogen as well as improvements in the hygiene and living conditions of the patient. A fundamental tenet is to debride the crust (scab) from the wound surface using poloxamer 188. If the lesions are not widespread, topical mupirocin is the treatment of choice. Treatment of bullous impetigo is similar, except that the local cleansing and topical antibiotic must be complemented by systemic antibiotics if there is evidence of disseminating infections. Ecthyma is usually a consequence of failure to treat effectively impetigo. The untreated infection extends deep into the tissue in shallow ulcerations that often heal without scar. Treatment for ecthyma usually requires systemic antibiotics against either staphylococcus or streptococcus. Folliculitis is a pyoderma located within a hair follicle, secondary to follicular occlusion by keratin, overhydration, or either bacterial or fungal infection. Folliculitis may be divided into either a deep or a superficial type. In the superficial type, the pustule is located at the opening of the hair follicle. In the deep form, the infection may extend beyond the confines of the hair follicle, becoming a furuncle or boil. Carbuncles are aggregates of interconnected furuncles that drain through multiple openings of the skin. Treatment of folliculitis must include searching for and avoiding any factors predisposing to infection. If topical antibiotic therapy is ineffective in controlling the infection, surgical drainage of the infected skin abscess will be necessary. Paronychia is the most common bacterial infection of the hand, which often requires surgical incisional drainage. Similarly, a felon that is an infection of the distal pulp of a finger usually requires surgical drainage. Finally, cellulitis is an acute inflammatory reaction involving the skin and underlying subcutaneous tissue. It usually starts as erysipelas and may advance to lymphangitis, lymphadenitis, or gangrene,which will respond to life-saving interventions in the hospital that usually include systemic antibiotic treatment as well as surgical intervention.

Acute paronychia heralding the exacerbation of pemphigus vulgaris

Acute paronychia, the suppurative inflammation involving the paronychium of the nails, is usually caused by bacterial or fungal infection and has been rarely reported as a presentation of pemphigus vulgaris (PV). We report a woman with PV who presented with suppurative paronychia of multiple fingernails and toenails, which preceded the exacerbation of other mucocutaneous lesions. A biopsy specimen of the paronychium revealed suprabasal vesicles due to acantholysis. Systemic corticosteroids and adjuvant immunosuppressants were effective in treating mucocutaneous lesions as well as nail disease. We conclude that in patients with PV, acute paronychia could be a manifestation of the disease per se, rather than an infectious process. Only the precise diagnosis with adequate immunosuppressive treatment can lead to good control of disease activity.

Managing simple chronic paronychia and onycholysis with ciclopirox 0.77% and an irritant-avoidance regimen

Dermatologists and other physicians frequently encounter simple chronic paronychia and onycholysis. In addition to strict avoidance of contact irritants, a broad-spectrum topical antifungal agent has been recommended. We conducted an examination of treatment with this type of agent and an assessment of the efficacy of ciclopirox 0.77% topical suspension in combination with a strict irritant-avoidance regimen. Early results of a pilot study (N = 44) using ciclopirox 0.77% topical suspension in patients diagnosed with simple chronic paronychia and/or onycholysis show excellent therapeutic outcomes of a combined regimen of a broad-spectrum topical antifungal agent such as ciclopirox and contact-irritant avoidance in this patient population.

Herpetic whitlow during isotretinoin therapy

Isotretinoin is an extremely valuable drug that is occasionally associated with well-known mucocutaneous side-effects, including cheilitis, retinoid dermatitis, palmoplantar desquamation, and photosensitivity. Paronychia has been reported rarely: only two prior cases of herpes simplex infections associated with isotretinoin have been previously reported. We present the first known case of herpetic paronychia occurring in an atopic patient while on isotretinoin therapy for acne.

[Local treatment of purulent wounds with kukumazim]

The authors describe the results of treatment of 245 patients with pyo-necrotic diseases of soft tissues with a new proteolytic enzyme of vegetable origin Kukumazim. The application of Kukumazim resulted in a 5-6 days shorter period of complete healing the wounds. No adverse effects of using Kukumazim were noted.

Topical steroids versus systemic antifungals in the treatment of chronic paronychia: an open, randomized double-blind and double dummy study

BACKGROUND

The involvement of Candida in the pathogenesis of chronic paronychia (CP) has never been proven, even though this condition is commonly considered a type of Candida onychomycosis.

OBJECTIVE

The purpose of this study was to compare the efficacy of systemic antifungals (itraconazole or terbinafine) with a topical corticosteroid (methylprednisolone aceponate) in the treatment of patients with CP.

METHODS

The study involved 45 adult patients with CP. Medication was given in a randomized, double-blind and double dummy manner over 3 weeks. Patients were then followed for 6 weeks. Clinical and mycologic evaluations were performed at baseline, and at weeks 3 and 9. The efficacy measures included clinical and photographic evaluation.

RESULTS

Of 48 nails treated with methylprednisolone aceponate, 41 were improved or cured at the end of the follow-up period. The statistical analysis showed a significant difference between the number of nails improved or cured by methylprednisolone aceponate and that of nails improved or cured with terbinafine (30 out of 57) or itraconazole (29 out of 64). Presence of Candida was not strictly linked to disease activity, and Candida eradication was associated with clinical cure in only 2 of the 18 patients who carried Candida at the beginning of the study.

CONCLUSION

This study shows that topical steroids are more effective than systemic antifungals in the treatment of CP, and supports the view that CP is not a type of onychomycosis but a variety of hand dermatitis caused by environmental exposure.

[Chronic paronychia and synovialitis of extensor tendons due to Mycobacterium marinum. Is diagnosis or treatment the problem?]

Most infections of the upper extremity are caused by staphylococcus or streptococcus and respond well to beta-lactam antibiotics. Hand surgeons should be aware of the possible diagnosis of Mycobacterium marinum infection: 90% of the lesions are found in the upper extremity. We present a case of a chronic, cutaneous lesion of the right middle finger with synovialitis of the extensor tendons observed in a 35-year-old woman. Routine cultures from tissue of the infected finger led to the diagnosis of paronychia due to staphylococcus aureus. Despite surgical and antibacterial treatment, the lesion persisted and the patient developed multiple raised, non-tender satellite lesions to the right hand and elbow. Based on the clinical aspect and a detailed history (she kept fish and had suffered a chicken bone stab to her middle finger 12 weeks earlier), we suspected a Mycobacterium marinum infection. Tissue was obtained mainly by synovialectomy. Culture of the biopsy tissue for Mycobacterium marinum confirmed the diagnosis. The patient responded to a triple therapy (rifabutin, ethambutol and clarithromycin) and had an uncomplicated recovery. The importance of a high index of suspicion, adequate examination and a complete patient's history for a correct diagnosis is stressed. Culture for Mycobacterium marinum is not routinely performed and ought to be initiated once an infection is suspected. We also discuss the best timing for the onset of medical treatment.

Myeloma-associated systemic amyloidosis presenting as chronic paronychia and palmodigital erythematous swelling and induration of the hands

Mucocutaneous involvement occurs predominantly in primary systemic amyloidosis as well as in myeloma-associated systemic amyloidosis. It is rarely observed in other types of amyloidoses. Signs of such involvement may aid in the early diagnosis of the disease process. Herein, we describe a 64-year-old white male patient with myeloma-associated systemic amyloidosis in whom the disease presented with unique cutaneous lesions consisting of chronic paronychia and palmodigital erythematous swelling and induration of the hands. Following weekly regimens with prednisone (20 mg/day) and melphalan (2 mg/day) administered every 16 weeks, almost complete resolution of the cutaneous lesions was observed after 1 year of therapy. Also, in response to chemotherapy, modest regression of the myelomatous bone lesions and complete resolution of the underlying gammopathy occurred.

Perionychial infections associated with sculptured nails

Two cases of perionychial infections associated with the use of sculptured fingernails are presented. Both patients developed paroncyhia necessitating incision and drainage. One patient, a diabetic, had a concomitant subungual abscess and felon which required repeat drainage and debridement as well as intravenous antibiotics over an extended period for complete resolution. Sculptured fingernails may be risk factors for the development of digit infections through various mechanisms, and users of these cosmetic devices, especially diabetics and immunocompromised people, should be made aware of their potential for infectious complications.

Paronychia associated with antiretroviral therapy

We report six HIV patients who developed painful periungual inflammation of several nails during treatment with the antiretroviral drugs indinavir and lamivudine. The lesions appeared 2-12 months after starting treatment. The occurrence of paronychia in HIV patients has recently been reported in two groups of patients receiving either indinavir or lamivudine. Dermatologists should be aware of this recently reported and probably not uncommon side-effect of antiretroviral treatment in order to avoid an invasive approach to the nail lesions.

[The role of angiotrophoneurosis of the upper extremity in the course of complicated forms of paronychia]

The degree of the influence of angiotrophoneurosis on the development and outcome of purulent diseases of fingers and hand is analyzed on the basis of treatment of 394 patients with complicated forms of panaritium. It was established that angiotrophoneurosis is a predisposing factor to the development of complicated forms of panaritium and profound phlegmons of the hand. A scheme of using reovasotropic medicines is proposed for the compensation of trophic lesions of tissues of the upper limb distal segments.

[The parenteral administration of terridecase in the treatment of suppurative-inflammatory diseases of the hand]

Patients with purulent inflammatory diseases were treated by parenteral administration of terrydecaza (polyglucin-immobilised terrylythin). It was noted that injections of terrydecaza facilitated the penetration of antibiotics to the purulent focus. The terms of cleansing the purulent wounds and transition of the inflammatory process to the second stage were 2-3 days shorter. The microcirculation was improved by the daily thermographic monitoring method. The increased penetration through the biological membranes was confirmed by higher concentration of middle weight molecules in plasma of the venous blood flowing off from the purulent focus.

Symmetrical necrotising chest wall infection following paronychia

Paronychial infection is a common condition seen in the accident and emergency department. Treatment is by antibiotics or incision and drainage under local anaesthetic. Complications are rare but may occur if treatment is delayed or inadequate. A case is described of symmetrical necrotising chest wall infection, of unusual anatomical distribution, that occurred following a paronychia and required surgical debridement and skin grafting.

Paronychia--a manifestation of pemphigus vulgaris

Involvement of the nail unit in pemphigus vulgaris is thought to be uncommon. However, trachyonychia, nail atrophy, onychomadesis, onycholysis, nail bed erosion, onychoschizia, subungual haemorrhage, nail pitting, nail plate discoloration, cross-ridging of nail plate, Beau's line and paronychia have been reported. These manifestations may be due either to secondary extension of the bulla adjacent to the nail or primary involvement of the nail bed, nail matrix and nail fold. We report four patients with pemphigus vulgaris who developed paronychia with a corresponding exacerbation of their cutaneous lesions. Nail fold biopsy and direct immunofluorescence revealed features of permphigus vulgaris. Treatment with immunosuppressive agents showed simultaneous improvement of both cutaneous and nail lesions.

Congenital cutaneous candidiasis: case report and review

This report describes a preterm infant with congenital cutaneous candidiasis associated with paronychia, dystrophy of the nail plates, and marked, transient leukocytosis.

Primary herpetic gingivostomatitis with multiple herpetic whitlows

This paper provides a case report and review of the literature of the presentation of multiple herpetic whitlows with primary herpetic gingivostomatitis. The management of the condition is discussed.

Antifungal therapy of yeast infections

Candida infections of the skin and mucous membranes are common in both healthy and immunocompromised patients. Management with topical azole or polyene therapy is generally straightforward except in immunocompromised patients with oropharyngeal infections and in Candida onychomycosis. Oral candidosis in patients with AIDS generally requires oral therapy with fluconazole, itraconazole, or ketoconazole. Continuous suppressive therapy carries the risk of the development of clinical tolerance or secondary drug resistance. In nail disease, oral antifungal therapy is appropriate except in paronychia, for which topical azole antifungals appear to be equally effective. In any case it is important to determine whether Candida isolated from nail material is a true nail pathogen or merely colonizing the nail plate. Distal erosion of the nail plate, the presence of underlying host abnormalities such as Raynaud's disease, and hyphae in the nail plate are clues that organism is invading the nail plate.

[Herpes simplex digitalis--an important differential diagnosis of paronychia]

Herpes simplex infection of the hand is often falsely diagnosed as a pyogenic paronychia or felon and treated as such, because the clinical picture is not known and pathogen isolation is difficult. However, the surgical treatment of herpes digitalis is contraindicated, since it promotes the development of superinfections and triggers recurrence. The pathogen can be isolated in cell cultures prepared from the vesicle contents or a smear from the vesicle base. Serological antibody testing is unreliable. Topical application of Acyclovir cream (Zovirax) is the treatment of choice.

Advances in the treatment of superficial candida infections

This article reviews recent controlled studies of treatment for candida infections of the skin and mucous membranes. In general, excellent agents are available for treatment, with reasonable alternatives for the uncommon emergence of resistant strains. Cutaneous infections in immunocompetent patients are effectively treated with topical agents. The major clinical problems that remain include frequently recurrent vulvovaginal candidiasis, and oroesophageal candida infections in patients with malignancies and immunosuppression. These often require systemic therapy. A number of treatment strategies have been investigated and are reviewed.