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An otherwise healthy 3-year-old girl presented with a several-month history of scaly lesions on her palms and soles. The lesions on the palms and right sole had been successfully treated with a steroid for pompholyx by a nearby dermatology clinic, but the lesion on the left sole persisted and spread to the back of the foot. On the initial visit, the patient exhibited an itchy and scaly erythematous left foot lesion. Direct microscopic examination of the scales revealed a considerable amount of fungal elements. A diagnosis of tinea pedis was made, and antifungal treatment with a neticonazole ointment was initiated. Complete cure was achieved after 4 weeks of treatment. The primary mycological cultures from the scales simultaneously revealed two types of colonies: a white powdery flat colony and a white downy elevated colony with a reddish-yellow bottom. Although the powdery colony was identified as Trichophyton mentagrophytes complex on slide culture, the downy colonies could not be identified based on cultural and morphological characteristics. The nucleotide sequences of the internal transcribed spacer region from both colonies showed an exact match, which eventually led to their identification as Trichophyton interdigitale. Further genotyping at three points in the non-transcribed spacer region in both colonies also showed the same NTS type of D2II. It is very rare for two morphologically different colonies to be isolated from the primary culture under the same conditions in tinea cases. Genetic tests are of extreme value to identify the strain in such cases.

67-year-old female patient developed drug-induced liver dysfunction after taking oral itraconazole (ITCZ) for the treatment of kerion celsi. Red papules appeared on the temporal area of the patient one month prior to her visit to our clinic. The patient presented with a nodule with yellow crust, erosion, infiltration, and hair loss on the area. Diagnosis of kerion celsi caused by Trichophyton rubrum was made from clinical, pathological, and mycological findings. Laboratory data showed normal liver function, and the patient was not taking any other medication, thus, daily oral ITCZ 100 mg was started. The skin lesion improved, but severe liver dysfunction was found 1 month after starting ITCZ. Oral ITCZ was therefore terminated, and the patient was admitted to a medical ward for the treatment of liver dysfunction. Hepatobiliary enzymes increased after admission: AST 232 IU/L, ALT 465 IU/L, T-bil 6.1 mg/dL, and D-bil 3.9 mg/dL. The patient was kept at rest and was given oral ursodeoxycholic acid. Hepatobiliary enzymes returned to normal level 2 1/2 months after starting ITCZ. The skin lesion healed without further treatment. No recurrence was observed. It is noteworthy that liver function has to be carefully monitored during treatment with oral ITCZ.

BACKGROUND To identify the pathogenic fungi of dermatophytosis, restriction fragment length polymorphism (RFLP) analysis of PCR amplified ribosomal DNA including internal transcribed spacers (ITS) has been established in Japan. Our purpose was to evaluate the usability of PCR-RFLP analysis to identify the causative agent of tinea unguium directly from a nail sample. METHOD Samples of tinea unguium from 100 nails were collected and cultured on Sabouraud's glucose agar and observed for 2 months. DNA was extracted from these samples, and the PCR product was digested with restriction enzymes Mva I and Hinf I. Weight of the samples was determined. RESULT Sensitivity of PCR-RFLP analysis (73%) was higher than that of culture (20%) showing that PCR is more advantageous for identification of the causative agent of tinea unguium. Sensitivity of PCR-RFLP did not depend on weight of the nail sample.

We report a case of lymphocutaneous sporotrichosis in a 69-year old man who had nodular-ulcerated lesions on the right hand and forearm. Small nodules remained on the right hand after 8 weeks of 0.5 g daily treatment with potassium iodide. Alternatively, terbinafine therapy (125 mg/day) resulted in healing with atrophic scars after 9 weeks without side effects. We reviewed 67 patients of cutaneous sporotrichosis in Japan from 1993 to 1999. Those cure rates (and mean durations of treatments in parentheses) are 90.9% (8.1 weeks) with potassium iodide, 86.6% (12.6 weeks) with itraconazole (100 mg/day) and 71.4% (12.8 weeks) with terbinafine (125 mg/day) treatments, respectively. These results lead us to consider a daily dose of 250 mg as more appropriate for terbinafine.

Although the role of exfoliative toxin in staphylococcal scalded-skin syndrome has been suggested to be that of a serine protease, it has not been demonstrated to show proteolytic activity. Our purpose was to purify a proteolytic enzyme from a mixture of exfoliative toxin and newborn-mouse epidermis. We used gel filtration and ion-exchange and hydroxyapatite chromatography with a high-pressure liquid chromatography system. A casein-hydrolyzing enzyme was isolated from the mixture. The molecular mass of the enzyme was confirmed to be 20 kDa by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Subcutaneous injection of the purified enzyme into newborn mice reproduced the epidermal splitting that is seen in staphylococcal scalded-skin syndrome. These results suggest that exfoliative toxin does not work as a protease itself but that some reaction between exfoliative toxin and an epidermal component(s) first produces a protease, after which epidermal splitting occurs.

We investigated the epidemiology of 618 patients of mucocutaneous candidiasis who visited our outpatient clinic between 1993 and 1997. Compared with previous reports in Japan, the incidence of candida intertrigo increased and that of erythema mycoticum infantile decreased. The incidence of "others", such as nail candidiasis and candidiasis developed under plaster increased. We identified the species of Candida from patients in 496 recent cases, and these species were cultured successfully in 79.2%. As reported by previous authors, a majority or our results were Candida albicans serotype A. We also investigated the risk factors such as diseases or conditions which might be related to immunodeficiency (neoplasm, AIDS) and that might force a patient to restrict himself to bed for a long period (neurological disease). The former was found in 22.7%, and the latter in 23.3% of patients.

We evaluated the minimum period for penetration of Trichophyton mentagrophytes into human stratum corneum using an experimental model of tinea pedis. Fungal elements were applied to the surface of stratum corneum which were obtained from a healthy human heel, and samples were incubated under a designated condition of temperature and humidity. Thirty-five degrees, which is the approximate temperature of the surface of human skin, seemed more suitable for penetration than 27C. The result also indicated that humidity was a more significant factor than temperature. In the following examination using T. mentagrophytes and T. rubrum, the minimum period for penetration at 100% humidity was 1 day with the former and 1.5 days with the latter. At 95% humidity, T. mentagrophytes penetrated into human stratum corneum on day 1.5 and T. rubrum penetrated on day 4. Humidity of the 4th interdigital space in daily life was calculated to be below 95% using a hygro-thermometer. Therefore, to wash the feet daily can prevent development of tinea pedis. When we applied fungal elements to a cut side of stratum corneum, fungi penetrated within a day at 100% and 95% humidity. In addition, fungi were able to penetrate at below 85% humidity, which they were unable to do when applied them to the surface side. We stress that minor injury of stratum corneum is also a significant factor of the development of tinea pedis.

We present results on the experimental penetration of Trichophyton mentagrophytes and T. rubrum under designated condition of humidity into human stratum corneum obtained from a healthy human heelregion. When mycelia were applied to the surface side of stratum corneum and then incubated at 100 % humidity, T. mentagrophytes and T. rubrum were observed in the stratum corneum on day 1 and day 1.5, respectively. At 95% humidity, T. mentagrophytes and T. rubrum penetrated on day 1.5 and day 4, and at 90% humidity, they penetrated on day 3 and day 7, respectively. At less than 85% humidity, no fungal elements of either strain were observed in stratum corneum for up to 7 days. These datasuggest that at least 90% humidity is necessary for these two fungi to penetrate into stratum corneum within a few days. However, when T. mentagrophytes was applied to the cutting side of the stratum corneum and thenincubated at more than 70% humidity, the mycelia were able to penetrate within a day. The same results were obtained when T. rubrum was applied on the cutting side and incubated at 95 and 100% humidity. T. rubrum was also able to penetrate into the stratum corneum within several days at 70 and 80% humidity. These results may indicate that not only persistent moisture but also minor injuries of stratum corneum are the most important factors in the development of tinea pedis.

We report two cases of dermatophytosis of the external auditory meatus. Case 1: A 44-year-old man suffered from severe itching in the right external auditory meatus for a year, and had also had tinea unguium for several years. He visited our outpatient clinic because of scaly erythema which had developed on the auricle. Otoscopic examination revealed yellow-brown dry cerumen and redness from the cartilaginous to the bony portion of the external auditory meatus. Case 2: A 14-year-old boy, the son of Case 1, suffered from severe itching in the left external auditory meatus. He scratched the auditory meatus with an earpick which his father had used. Otoscopic examination revealed a similar lesion as in the father's case, although he had no history of dermatophytosis elsewhere on his body, including the auricle. Direct examination using a KOH method of the cerumen from both cases demonstrated numerous fungal elements. Fungal culture identified Trichophyton rubrum. Both cases were successfully treated with oral itraconazole. We suggest that infection from father to son was transferred by the earpick.

兎が感染源と考えられる,Trichophyton mentagrophytesによる白癬の2例を報告した.症例1は28歳,女性.初診の3か月前より,室内で2羽の兎を飼育していた.2か月前に1羽の兎に脱毛巣を生じ,その直後に別の兎に同様の症状が生じた.初診の10日前より胸部の皮疹に気づき来院,病巣よりT.mentagrophytesを分離した.兎は既に治療済みであったが,動物病院に保存されていた菌株についてT.mentagrophytesと同定できた.症例2は,3歳,男児.初診の約1か月前に体部白癬に罹患.某医を受診し治療をうけ,これは治癒したが,2-3週間前より頭部の鱗屑と脱毛に気づき,同じ医院を受診.頭部白癬の診断で外用抗真菌剤による治療を受けていたが,ケルスス禿瘡に進展したため来院.病巣よりT.mentagrophytesを分離した.内服抗真菌剤による治療継続中,亜鉛華軟膏を併用したところ,著しい増悪を招き,外用の中止により急速に改善した.初診の約2か月前より室内で飼育していた兎に,患児の臨床像に類似した鱗屑と痂皮を伴う脱毛巣があったという.兎は既に治療済みであったため,兎から菌を分離する事はできなかった.なお,患児より分離したT.mentagrophytesは,交配試験の結果Arthroderma vanbreuseghemii(-)株と同定された.

平成6年の1年間に当科を受診した皮膚・粘膜カンジダ症について,主として菌学的な統計をおこなった.患者数は121名で,132病型観察された.この132の病変部より115株のカンジダ菌種が分離され,その内1株を除き,114株が同定された.この114株には,同一病巣より2種の菌が同時に培養された4株も含まれている.菌種の同定は,主としてカンジダチェックおよびAPI 20Cオクサノグラムの両者の供用により決定した.両者の結果が一致しなかった菌は7株みられた.この内のC. albicans Bについては,カンジダチェックの結果を優先し,他の菌については,germtube testの結果と合致したものを最終結果とした.分離された菌の菌種別分離頻度は,Candida albicans A 93株(81.6%),C. tropicalis 8株(7.0%),C. parapsilosis 6株(5.3%),C. albicans B 4株(4.4%),C. glabrata 2株(1.7%)であった.今回のカンジダチェックによる同定率は,約98%と推定された.C. albicans Bは,全株股部や外陰部より分離されており,1株を除き,重篤な基礎疾患は見られなかった.C. parapsilosisについても重篤な基礎疾患は少なく,全例手や指趾の病巣より分離された.C.tropicalisは,希な病型から分離されたものが多く,基礎疾患は重篤なものが多いように思われた.

38歳、左1,3指爪甲の黄濁と左手掌ほぼ全体の角化を主訴に来院.初診時のKOH直接鏡検にて,爪甲下角質には多数の胞子の集団と菌糸が認められたが,手掌の鱗屑からは多数の菌糸以外に明らかな胞子様菌要素は認められなかった.当初爪カンジダ症と手白癬の診断にて,イトラコナゾール内服,テルビナフィンクリームの外用による治療を開始した.しかし初診時に施行したサブロー培地による培養の結果,爪,手掌の両者からCandida parapsilosis, C.tropicalisの2種類の菌が分離され,治療開始1週間後の,爪および手掌の鱗屑のパーカーKOH直接鏡検所見も同じ結果であった.しかし,培養の結果は,爪は同じカンジダが培養されたものの,手掌の鱗屑からは何等の菌も培養されなかった.同時に施行したthiamin,inositol含有BHI培地による培養でも菌は培養されなかった.抗カンジダ血清を用いた酵素抗体法では,爪には無数の菌要素を認め,手掌の鱗屑には少数の菌要素がPAS陽性部に一致して検出された.以上の検査所見から,爪カンジダ症及び角質増殖型カンジダ症の合併と診断した.

We evaluated the minimum time for penetration of Trichophyton mentagrophytes into human stratum corneum using an experimental model of tinea pedis. After fungal elements were applied on the surface of stratum corneum obtained from a healthy human heel, samples were incubated under designated conditions of temperature and humidity. The penetration of fungal elements was much faster at 35 degrees C than 27 degrees C despite the fact that the latter is an optimal temperature for fungal growth. At 35 degrees C and 100% humidity the minimum time required for penetration was one day. When we applied fungal elements on an abraded surface of stratum corneum, fungi penetrated within a half day under the same conditions. This suggests that minor injury of stratum corneum is a significant factor for infection. The development of tinea pedis does not occur frequently in daily life. We examined the effect of washing the surface of stratum corneum to which T. mentagrophytes had been applied. The samples were incubated under conditions simulating daily life: i.e. with 80% humidity for 8 hours, and 100% humidity for 16 hours. After washing, nearly all the fungal elements had been removed from the surface of stratum corneum within one day. The data suggests that to prevent tinea pedis, daily washing of soles and interdigital regions is effective.

A 63-year-old healthy female patient presented with well defined itchy erythematous lesions on the area of her eyebrows. Her eyebrows had been tattooed two months before her visit to us. The lesions had previously been treated by application of steroid ointment and anti-histamine and steroid tablets by mouth without success. We suspected the lesions to be contact dermatitis caused by some metal element contained in the dye used for tattooing. Treatment was continued for two weeks, but the lesions spread to her cheeks and forehead. No fungal element was found from the lesions by direct microscopy at this stage. The patch-testing to 20 metal substances on her skin showed no allergic reaction. After one more week of treatment, we reexamined the scale taken from the lesions by direct microscopy, and fungal elements were found at that time. Microsporum (M.) gypseum was isolated from the scale taken from the lesions. The lesions cleared after treatment of 11 weeks' oral intake of itraconazole 100mg daily. It was found that the patient was accustomed to sleep with her dog, a Chihuahua. On examination by a veterinarian, no skin lesions were found on the dog. We speculate that the paws of the dog might have carried soil contaminated by M. gypseum, a geophilic fungus, to the area of her eyebrows which had minor trauma after being tattooed.

We report a case of seborrheic blepharitis treated with oral itraconazole during a short period. Direct examination using Parker KOH revealed numerous hyphae and spores of Malassezia in the scale. Low-dose itraconazole pulse therapy (200 mg daily, 7 days a month) was quite effective. This is the second case in which we also observed a unique fungal conformation which looked like tinea versicolor. The evidence strongly suggests that Malassezia is one of the major causative agents of seborrheic blepharitis.

Dermatophytosis of the external auditory meatus is believed to be a fairly rare disease. In the past three and a half years we have had seven cases of dermatophytosis in the external auditory meatus. All cases except one were associated with tinea of other lesions. Case 1: A 44-year-old man had tinea of the auricle, tinea pedis and tinea unguium. Case 2: A 14-year-old boy, the son of case 1 had no tinea elsewhere on his body, including the auricle. He scratched the auditory meatus with an earpick which his father had used. Case 3: A 62-year-old man had tinea of the auricle, tinea pedis and tinea unguium. Case 4: A 50-year-old man had tinea of the auricle, tinea pedis and tinea unguium. Case 5: A 36-year-old man had tinea of the auricle, tinea pedis, tinea unguium and tinea cruris. Case 6: A 30-year-old woman had tinea of the auricle. Case 7: A 68-year-old man had tinea of the auricle, tinea pedis, tinea unguium and tinea manuum. Endoscopic examination (except for cases 4 and 7) revealed dry cerumen from cartilaginous to bony region of the external auditory meatus. Direct examination using KOH method of the cerumen in all cases demonstrated numerous fungal elements. Fungal cultures identified Trichophyton rubrum except for cases 3 and 6. All cases were successfully treated with oral itraconazole or terbinafine. We suggest that tinea of the external auditory meatus is frequently associated with that of the auricle.

We report two cases of candidal onychomycosis with severe nail deformities. Case 1: The patient was an 81-year-old man who complained of onycholysis and nail deformity of the right forefinger nail which had occurred over a period of a year. He had no obvious previous illness. Case 2: The patient was an 81-year-old woman who complained of nail deformity with periungual erythema which had occurred over a period of several months. She had been treated with oral corticosteroid for bronchial asthma and with Ca blocker for hypertension for a long period. The initial KOH-prepared direct microscopy in each case failed to detect any spores or pseudohyphae. Therefore, an incisional biopsy was performed in both cases. Histopathological findings demonstrated numerous fungal elements with similar appearance of dermatophytes in the middle to lower level of the horny cell layer by PAS and Grocott staining in each case. Candida albicans was isolated and identified by cultivation on ATG agar. In case 1, oral itraconazole (100 mg/day) was administered for 14 weeks, which was effective clinically and mycologically. In case 2, however, a coadministered drug (Ca blocker), oral terbinafine (125 mg/day) was not effective mycologically. Therefore, after having changed the antihypertensive agent, oral itraconazole (100 mg/day) was administered for 16 weeks, which was effective clinically and mycologically.

We report the efficacy of miconazole nitrate shampoo (Furfur Shampoo) to prevent T. tonsurans infection.Experimental models were made from stratum corneum of healthy human heel or guinea pig skin. Before and/or after T. tonsurans was applied, samples were washed with miconazole nitrate shampoo, then inoculated on a Sabouraud culture plate.Though miconazole nitrate shampoo did not eliminate T. tonsurans on the sample completely, the time required to develop the colony (9.9 days) was obviously extended (7.7 days by control).We concluded that miconazole nitrate shampoo is a useful method of preventing T. tonsurans infection, and should be used every day (before/after the chance to infect).

After several types of dermatophytes were applied to the stratum corneum obtained from a healthy human heel, we evaluated the penetration speed of fungal elements into the stratum corneum and the effect of washing its surface. We designed the following two environments, assuming tinea pedis after applying fungal elements to the surface of the stratum corneum. The samples were incubated under conditions simulating the daily life of those who wear socks in a house: (1) 90% humidity for 8 hours, and 100% humidity for 16 hours, and those who have bare feet in a house: (2) 80% humidity for 8 hours and 100% humidity for 16 hours. We took the samples out every 24 hours and made observations by PAS stain and scanning electron microscope before and after washing them. Although fungal elements were not removable in (1), even if washed one day later, they could be removable one and two days later in (2). We suggest that fungal elements were easily removable even if dermatophytes had begun to penetrate the surface of the stratum corneum, because the soles retained a low humidity when the shoes were removed, and the soles and interdigital regions were washed every day. Moreover, in an experiment assuming tinea corporis, fungal elements were applied to the cutting side of the stratum corneum, incubated at 80% humidity, and observed after PAS stain. The penetration of Trichophyton tonsurans to the cutting side of the stratum corneum began in 0.5 days, which was sooner than other dermatophytes. We believe this is one factor of the latest expansion of T. tonsurans infection in Japan.

Thirty-six patients with tinea unguium were treated with 200 mg of itraconazole daily for 7 days each month. We suggested that a patient who had a lesion in the thumbnail needed 5 months of treatment for mycologial cure, while in a patient without thumbnail lesion, 3 months of treatment was enough.

A fifty five-year old woman suffered from itching and scaling of the edge of her eyelid. She had long used topical corticosteroid for this condition. Direct examination of the scale by Parker KOH showed numerous fungal elements of spores and hyphae of Malassezia furfur. She was treated with oral itraconazole (100 mg daily or twice a week) for 8 weeks and was cured clinically and mycologically. The result suggests the possibility of treatment with an anti-fungal drug for seborrhoeic blepharitis or seborrhoeic dermatitis.