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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.

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.

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 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.

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.

脂漏性皮膚炎患者より分離されたMalassezia furfurの生菌浮遊液(0.2g/ml)0.2mlを,剃毛したモルモットの背部と耳介後面,および,C3Hマウス並びにBALB/c nu-nuヌードマウスの背部に1日1回連日塗布した.モルモットについては,生菌試料の他,菌体抽出分画液,Dixon液体培地,およびエベラクトンBを添加した生菌試料を各々連日塗布した.モルモットへの生菌試料の塗布の結果は,7日目頃より脂漏性皮膚炎類似の鱗屑を伴う紅斑が出現し,25日目には背部12部位中9部位,耳介後面12部位中10部位に同様の病変を認めた.今回初めて塗布した初回塗布群に比べ,以前に塗布実験を行い,今回再び塗布した再塗布群に,より早期に病変が生じた.エステラーゼ阻害物質であるエベラクトンBの添加によりこの病変形成は抑制された.ヌードマウスへの結果は,背部に粃糠様鱗屑が認められたが,C3Hマウスには病変が形成されなかった.モルモットへの菌体抽出分画およびDixon液体培地の塗布の結果は,いずれも病変の形成に至らなかった.以上の結果から,M.furfurが脂漏性皮膚炎の一因であることが強く示唆され,さらに,その成因として,接触アレルギーの他,菌による皮脂の分解産物の直接作用も関与していることが推測された.

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.

In order to elucidate the effectiveness of anti-mycotics in treating seborrhoeic dermatitis, an attempt was made to isolate Malassezia from seborrhoeic lesions of patients of seborrhoeic dermatitis. The results revealed that, in male patients, 46/49 cases were positive for Malassezia furfur on the face and 30/48 cases were positive for M. furfur on the scalp. In female patients, 7/13 cases were positive for M. furfur on the face, and 6/17 cases were positive for M. furfur on the scalp. Anti-mycotic agents were excellent in 50% and good in 31% of the spore-positive cases, yielding an overall efficacy rate of 81%. In contrast, the treatment of the face with vehicle alone showed only one excellent result out of 8 cases. Although clinical improvement was rapid on the side treated with a topical corticosteroid in the half-side-test, numerous fungal elements remained. While the improvement with anti-mycotic agents was slower than that with the corticosteroid, clinical improvement became evident by the third week of administration and fungal elements disappeared.

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.

A total of 168 patients with tinea pedis, but without onychomycosis, were treated with 1 cycle of terbinafine (TBF) (1 cycle: defined as 250mg/day for 1 week). KOH preparation for direct microscopy was performed 4, 8 and 12 weeks after starting therapy to determine if testing was positive for tinea. Patients with no negative results on KOH examination or no evidence of obvious clinical improvement at 8 weeks, another cycle of the therapy was prescribed. The “cure, ” “no cure, ” “dropout, ” and “discontinuation/unevaluable” rates were 89.3%, 4.8%, 4.8% and 1.2%, respectively. The number of cycles required for cure in the plantar type was 1 cycle in 65.9% and 2 cycles in 54.5% of cases; in the interdigital type, 1 cycle in 79.1% and 2 cycles in 20.9% of cases; and mixed type, 1 cycle in 29.1% and 2 cycles in 60.9% cases. Among patients who were followed for at least 3 years after cure, the relapse rates were about 10% each year: 1 year, 11.3%; 2 years, 8.9%; and 3 years, 11.2%. The relapse rate of about 10% each year over a 3-year period suggests that reinfection may be likely.

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.

A 67-year-old housewife had polymorphous eruptions with tense bullae on the extremities and upper trunk. Erosions were noted on the oral and esophageal mucosa. A skin biopsy showed subepidermal blistering with linear deposition of IgG and C3 at the basement membrane zone. In addition, intercellular deposition was observed at the lower part of the epidermis. On the basis of clinical and histological features, a diagnosis of bullous pemphigoid (BP) was made. After she was treated with prednisolone, the whole-skin lesions soon disappeared. An esophageal biopsy showed intercellular deposition of IgG and C3. Indirect immunofluorescence testing using esophageal mucosa of guinea pigs showed the same deposition at the titer of 1:20. Immunoblottings with this patient's serum revealed no reactions with either BP or pemphigus antigens. Her serum reacted strongly with a 190-kD protein, the nature of which was unknown. A treatment with ciclosporin was added to this steroid therapy, and the mucosal lesions improved gradually.

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.