Eumycetoma and actinomycetoma--an update on causative agents, epidemiology, pathogenesis, diagnostics and therapy

Mycetoma is a chronic putrid infection of the cutaneous and subcutaneous tissue concerning predominantly the feet, and more rarely other body parts. Mycetoma can be caused by both fungi (eumycetoma) and bacteria (actinomycetoma). Mode of infection is an inoculation of the causative microorganism via small injuries of the skin. The clinical correlate of both forms of mycetoma is tumescence with abscesses, painless nodules, sinuses and discharge. The latter is commonly serous-purulent and contains grains (filamentous granules) which can be expressed for diagnostic purposes. Distinctive for both eumycetoma and actinomycetoma, are the formation of grains. Grains represent microcolonies of the microorganism in vivo in the vital tissue. The most successful treatment option for eumycetomas offers itraconazole in a dosage of 200 mg twice daily. This triazole antifungal is considered as 'gold standard' for eumycetomas. Alternatively, the cheaper ketoconazole was widely used, however, it was currently stopped by the FDA. Actinomycetomas should be treated by the combination of trimethoprim-sulphamethoxazole (co-trimoxazole 80/400 to 160/800 mg per day) and amikacin 15 mg/kg body weight per day. Mycetomas are neglected infections of the poor. They are more than a medical challenge. In rural areas of Africa, Asia and South America mycetomas lead to socio-economic consequences involving the affected patients, their families and the society in general.

Comparative efficacy and safety of amorolfine nail lacquer 5% in onychomycosis, once-weekly versus twice-weekly

Amorolfine is a new topical antifungal of the phenylpropyl morpholine class which is highly active both in vitro and in vivo against yeasts, dermatophytes and moulds responsible for superficial fungal infections. Human pharmacological studies have established that amorolfine has a persistent antifungal effect in the nail bed and in the skin without being systemically absorbed. This has been confirmed by clinical work showing that amorolfine is effective in treating dermatomycoses and onychomycoses when administered as cream or nail lacquer. It is ineffective when given orally for systemic mycoses or bacterial infections in animals. In earlier studies a 5% concentration of amorolfine nail lacquer was found to produce a better cure rate in onychomycosis than a lower concentration of 2%. From data available on the penetration of amorolfine and on the persistence of mycologically relevant tissue concentrations, it appeared likely that once- or twice-weekly application of nail lacquer should suffice to produce a satisfactory therapeutic effect in onychomycosis. The aim of this investigation was to assess the efficacy and tolerability of 5% amorolfine nail lacquer given once versus twice weekly to patients with onychomycosis of finger nails and toe nails.

Topical treatment of onychomycosis with amorolfine 5% nail lacquer: comparative efficacy and tolerability of once and twice weekly use

456 patients with onychomycosis were treated once or twice weekly for up to 6 months with amorolfine 5% nail lacquer in an open, randomized study. The patients were examined at monthly intervals during treatment and followed-up 1 and 3 months after completion of treatment. Slightly better cure rates were achieved with twice weekly use than with once weekly use (overall cure rates 54.2 vs. 46.0%, p = 0.4). An overall cure or improvement was achieved in 74 and 68% of patients receiving twice- and once-weekly treatment, respectively. The mycological cure rate was 76.1% for twice-weekly treatment and 70.6% for once-weekly treatment. The nail lacquer was extremely well tolerated; 4 out of 456 patients reported mild local irritation. Plasma levels of amorolfine were determined in 19 patients and found to be below the detection limit of 0.5 ng/ml in all cases.

[Sucessful treatment with clofazimine and itraconazole in a 46 year old patient after 32 years duration of disease]

Lobomycosis, caused by the fungal pathogen Lacazia loboi, is a chronic deep mycosis and is only found in Central and South America. Clinically the disease is characterized by shiny keloidal nodules appearing mainly on the exposed parts such as face and the upper and lower extremities. Therapeutically the surgical removal of the lesions is considered as the only successful treatment. We describe the therapeutic response of a patient with Lobo's disease treated for one year with a combination of clofazimine (100 mg/day) and itraconazole (100 mg/day). A complete clinical and histopathological remission of the disease was observed. The patient has been followed for three years.

S1 guidelines: Tinea capitis

Tinea capitis describes a dermatophyte infection of scalp and hair that predominately occurs in children. The diagnostic workup includes microscopic examination, culture and/or molecular tests. Treatment is guided by the specific organism involved and should consist of systemic agents as well as adjuvant topical treatment. The aim of the present update of the interdisciplinary German S1 guidelines is to provide dermatologists, pediatricians and general practitioners with a decision tool for selecting and implementing appropriate diagnostic and therapeutic measures in patients with tinea capitis. The guidelines were developed based on current international guidelines, in particular the 2010 European Society for Pediatric Dermatology guidelines and the 2014 British Association of Dermatologists guidelines, as well as on a review of the literature conducted by the guideline committee. This multidisciplinary committee consists of representatives from the German Society of Dermatology (DDG), the German-Speaking Mycological Society (DMykG), the German Society for Hygiene and Microbiology (DGHM), the German Society of Pediatric and Adolescent Medicine (DGKJ) and the German Society for Pediatric Infectious Diseases (DGPI). The Division of Evidence-based Medicine (dEBM) provided methodological assistance. The guidelines were approved by the participating medical societies following a comprehensive internal and external review.

Studies on the yeast flora in patients suffering from psoriasis capillitii or seborrhoic dermatitis of the scalp

In 65 patients with scalp psoriasis or seborrhoic dermatitis of the scalp, stool specimens, tongue swabs and scalp scales were examined for yeasts. The stool specimens showed in 70.8% of the patient group massive and in 7.7% moderate yeast colonization. Yeasts were found in 47.7% of the tongue cultures and in 12.5% of the scalp scales. Candida albicans was the predominant pathogen in the faeces and on the tongue. In comparison with a control group, frequency of yeasts in faeces and on the tongue in patients with psoriasis capillitii and seborrhoic dermatitis of the scalp could be shown to be significantly higher.

Topical 5-fluorouracil solution in the treatment of warts--clinical experience and percutaneous absorption

Disseminated warts in six patients were pre-treated with topical 5-fluorouracil solution three times daily for 5 consecutive days. Curettage was then carried out under local anaesthesia. During pre-treatment less than 0.1% of the dose applied was absorbed through the skin. The warts had not reappeared in 5 of the 6 patients at follow-up 1 year later.

S1 guideline diagnosis and therapy of cutaneous larva migrans (creeping disease)

GUIDELINE OBJECTIVES

These guidelines aim to enhance patient care by optimizing the diagnosis and treatment of infections due to creeping disease (cutaneous larva migrans) and to raise awareness among doctors of current treatment options.

METHODS

S1 guideline, non-systematic literature search, consensus process using a circular letter.

Non-dermatophyte fungi in onychomycosis-Epidemiology and consequences for clinical practice

Onychomycoses are difficult-to-treat fungal infections with a high recurrence rate that relates to the anatomic and pathophysiological conditions in the nail organ and the required extended duration of treatment. Clinical-epidemiological studies demonstrated that non-dermatophyte molds and yeasts are the primary causative agents in 20%-30% of onychomycoses. Mixed infections with dermatophytes are observed as well. Therefore, the causative agents should be determined by fungal culture and the antifungal treatment regimen should reliably cover non-dermatophytes, if appropriate. Systemic-topical combination therapy involving a broad-spectrum, locally applied antifungal may increase the mycological and clinical cure rates compared to monotherapy with systemic drugs.

Allergic contact dermatitis to naftifine. Report of two cases

We report on two cases of allergic contact dermatitis due to naftifine, an antimycotic substance. Epicutaneous tests were positive with the reagent itself but not with other compounds of the ointment. Additionally, one of the patients reacted to an ointment containing clotrimazole. Until now, only few cases of contact allergy to naftifine have been described, but an increasing number is expected.

S1 Guideline onychomycosis

Onychomycosis is a fungal infection of the fingernails and toenails. In Europe, tinea unguium is mainly caused by dermatophytes. The diagnostic workup comprises microscopic examination, culture and/or molecular testing (nail scrapings). Local treatment with antifungal nail polish is recommended for mild or moderate nail infections. In case of moderate to severe onychomycosis, oral treatment is recommended (in the absence of contraindications). Treatment should consist of topical and systemic agents. The aim of this update of the German S1 guideline is to simplify the selection and implementation of appropriate diagnostics and treatment. The guideline was based on current international guidelines and the results of a literature review conducted by the experts of the guideline committee. This multidisciplinary committee consisted of representatives from the German Society of Dermatology (DDG), the German-Speaking Mycological Society (DMykG), the Association of German Dermatologists (BVDD), the German Society for Hygiene and Microbiology (DGHM), the German Society of Pediatric and Adolescent Medicine (DGKJ), the Working Group for Pediatric Dermatology (APD) and the German Society for Pediatric Infectious Diseases (DGPI). The Division of Evidence-based Medicine (dEBM) provided methodological assistance. The guideline was approved by the participating medical societies following a comprehensive internal and external review.

Amorolfine spray in the treatment of foot mycoses (a dose-finding study)

A total of 382 patients with foot mycosis were entered into a dose-finding study. Patients were randomly treated with amorolfine spray 0.5% or 2% (double-blind) or cream 0.5% (open; used as a reference agent). The spray or cream was applied once daily for 4 weeks on average. At screening, in 348 patients evaluable for efficacy, a total of 381 fungi were isolated: Trichopyton rubrum (196), T. mentagrophytes (73), other dermatophytes (17), Candida albicans (65), other yeasts (23), and moulds (7). In 33 patients the fungal infection was mixed. Two weeks after the end of treatment, the culture was negative in 94.1% and 97.4% of patients treated with 0.5% or 2% amorolfine spray, respectively. The difference was not statistically significant. In the 0.5% cream group the culture was negative in 86.6% of patients. Nine out of 380 patients evaluable for safety had local adverse events: four (3.2%) in each of the spray groups, and one (0.8%) in the cream group. The most common local adverse events in the patients treated with spray were a burning sensation and dryness of the skin. In conclusion, both spray concentrations were highly efficacious and well tolerated. Further studies should show if more widely spaced treatment with amorolfine spray is as effective as daily administration.

Onychomykose

Onychomycosis is an infection of the finger-and/or toenails by fungal microorganisms. If untreated, the process advances and destroys the nail plate. It may spread to involve the skin and does not heal spontaneously. There are different clinical presentations of onychomycosis which vary with the nature of the fungus and how it invades the nail unit. These different clinical forms require different therapeutic approaches. The successful treatment of onychomycosis requires special knowledge of the various clinical presentations, of the differential diagnosis and of recent advances in medical mycology. Therefore onychomycosis is best treated by dermatologists.