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There is a paucity of data regarding demodicidosis-associated facial hyperpigmentation.To delineate the clinical, dermoscopic, and histopathologic features of demodicidosis-associated facial hyperpigmentation.Clinical and diagnostic data were collected from the medical files of patients who were referred to our outpatient dermatology clinic in 2006-2019 for evaluation of facial hyperpigmentation and were diagnosed with demodicidosis.The cohort included 19 patients (13 male) aged 42-76 years, all with Fitzpatrick skin type 3-4. All presented with mostly asymptomatic dusky, brown-gray, facial pigmentation, localized or diffuse with background erythema in 36.8% of cases, and skin roughness in 26.3%. Dermoscopy yielded characteristic findings of white gelatinous or opaque protrusions from hair follicles or infiltration of follicular openings with an amorphic material. A specific finding was perifollicular and reticulated pigmentation of the affected areas. Findings were confirmed on microscopic (n = 7) and histopathologic (n = 5) studies. Anti-demodectic treatment led to complete (73.6%) or partial (23.4%) resolution of pigmentation within 2 years.We describe unique clinicopathological and dermoscopic findings associated with an under-recognized type of facial hyperpigmentation caused by demodex for which we propose the term "pigmented demodicidosis." Demodicidosis should be added to the list of causes of facial hyperpigmentation.

Data on Demodex in the immunosuppressed state is limited, focusing mainly on patients with human immunodeficiency virus and hematological malignancies. The aim of this study was to describe the manifestations of facial demodicosis in diverse immunosuppressive states.The medical records of all patients followed at a Demodex outpatient clinic of a tertiary medical center from January 2008 to November 2020 were retrospectively reviewed. Data on patients who were immunosuppressed while with demodicosis were retrieved.The cohort included 28 patients (17 women and 11 men; median age, 58 years). Types of immunosuppression included treatments with hydroxyurea for polycythemia vera/essential thrombocytosis, mycophenolic acid, tacrolimus, and prednisone for liver and/or kidney transplantation, prednisone with cyclosporine/methotrexate/azathioprine/rituximab mainly for autoimmune diseases, mercaptopurine with/without anti-tumor necrosis factor alpha (TNF-α) for Crohn's disease, chemotherapy for neoplasms, anti-TNF-α for psoriasis, and Cushing's syndrome. The clinical types of demodicosis included: papulopustular, erythematotelangiectatic and fulminant rosacea, hyperpigmented, pityriasis folliculorum, pustular folliculitis, and dermatitis. The diverse clinical presentations led to various differential diagnoses. Topical treatment with ivermectin (monotherapy/combination with other treatments) was effective.Clinicians treating immunosuppressed patients should be familiar with the different forms of demodicosis and include them in the differential diagnosis of facial eruptions.

Cryptococcus neoformans is an opportunistic fungus which causes severe morbidity and mortality among immune-compromised patients. Cutaneous manifestations of systemic cryptococcosis are rare and may include a papulo-nodular rash, ulcers, cellulitis, molluscum contagiosum-like papules and more. The Tzanck smear is a well-known simple diagnostic test which can be performed bedside, in order to characterize cell cytology. Its classic use was in diagnosis of autoimmune blistering diseases or herpes virus infections. However, in recent years it has been used as an efficient diagnostic tool for other dermatologic conditions. We present a case of a 47-year old liver transplant recipient who presented with numerous cutaneous manifestations of disseminated cryptococcosis, initially diagnosed with bacterial cellulitis and non-melanoma skin cancer. With the aid of the Tzanck smear we rapidly established the correct diagnosis leading to swift treatment.

SummaryBackground The gold-standard method for dermatophyte identification involves direct microscopy and culture, which have inherent shortcomings. Only few molecular methods have been standardised for routine clinical work. Objectives To develop and test a platform for identifying the most common dermatophytes in Israel using multiplex real-time polymerase chain reaction (RT-PCR). Methods Specific primers were designed for the multiplex system (LightCycler 480) according to known cultures and validated by reference isolates. The dermatophyte detection rate was compared to smear and culture in 223 clinical samples obtained from a tertiary medical centre. Inconsistencies between methods were evaluated by sequencing. The RT-PCR was further evaluated in 200 community-based samples obtained from a health maintenance organisation and 103 military-personnel-based samples analysed at a central laboratory. Results In hospital-based clinical samples, complete concordance between methods was observed in 190 samples (85%; Kappa=0.69). In most cases of non-concordance, sequencing was consistent with RT-PCR results. RT-PCR correctly identified all smear- and culture-positive cases in community and military-personnel samples. The results were available within 4 hours. Conclusions The multiplex RT-PCR platform is a rapid and efficient method for identifying dermatophyte species in clinical samples and may serve as a first step in the diagnostic algorithm of superficial fungal infections. This article is protected by copyright. All rights reserved.

Dermatophytes are the most common cause of superficial fungal infections in humans. Deep dermatophytosis, however, is rare, described to date only in isolated case reports, usually in the setting of systemic immunosuppression. To present the 15-year experience of a tertiary dermato-mycology clinic with the diagnosis and treatment of deep dermatophytosis. Patients were identified by database search. Clinical, mycological, histological, and treatment data were collected from the medical files. Ten patients were identified: nine after solid-organ transplantation and one undergoing chemotherapy, all diagnosed within 3 years after beginning immunosuppression (average 7.5 months). The infective agent in nine cases was Trichophyton rubrum. All patients presented with concurrent superficial fungal infections. Complete resolution was noted in response to systemic antifungal agents. There was no histological evidence of hair-follicle involvement. The limitations of the study were the retrospective design and the small cohort size. This case-series study suggests that deep dermatophytosis is a separate entity, distinct from Majocchi’s granuloma. It occurs only in immunocompromised patients and is characterized by discrete nodules, an indolent course, the absence of follicular invasion, and proximity to a superficial dermatophyte infection. Systemic antifungal treatment leads to complete resolution. The urgent need for the treatment of superficial fungal infections in immunocompromised patients is emphasized.

Summary Onychomycosis is a fungal infection treated orally for prolonged periods of treatment, caused primarily by Dermatophytes, Candida species and non-dermatophyte moulds (NDMs). The prevalence of specific aetiology may differ in dependence of environmental, geographic and demographic factors, and may affect management of the infection. The objective of this survey was to analyse epidemiologic parameters of onychomycosis in Israel. Data of a cohort of 27 093 patients were collected from six centres during a 2- and 10-year period. The diagnosis was based on microscopy of KOH/calcofluor mounts of nail scrapings and culture isolation. A positive result indicates isolation of a fungus in culture. Data were analysed for each centre and expressed as range for the whole cohort, using the spss v18 software. Analysis included three epidemiologic parameters: fungal aetiology in toe- and fingernails; association with gender; association with age group. Dermatophytes were the major causative agents and Trichophyton rubrum the most frequent isolate. Candida species were more frequent in women fingernails; frequency increased with age and C. parapsilosis the most frequent species. NDMs were isolated at low rate and Aspergillus terreus was the most frequent isolate. This is a first large cohort of onychomycosis patients from Israel analysed by defined epidemiological parameters.

Mycetoma is a chronic soft tissue infection caused by fungal or bacterial pathogens, and is endemic in tropical and subtropical regions. Cases in developed countries outside the mycetoma belt are rare and usually imported by immigrants. Sporadic cases have been reported in Israel. Unpublished cases in the participating medical centers are reported. In addition, a systematic review of the literature was performed. All published mycetoma cases diagnosed in Israel were included with relevant variables collected. Twenty-one cases of mycetoma were diagnosed in Israel between 1942 and 2015, including four unpublished cases and 17 published cases. The mean age at diagnosis was 42 years (range 23-73), and 16 of the patients were male. The foot was the primary involved organ. Fifteen patients were immigrants from Yemen, Ethiopia, and Sudan. Five cases were autochthonous. One case was travel related. Among patients who developed symptoms after immigration, the mean time from exposure to symptom onset was 5.6 years (range 1-10 years). The mean time from symptom onset to diagnosis was 6.6 years (range 0.2-35 years). The autochthonous cases demonstrate that Israel is endemic of mycetoma. The immigrant population represents two distinct waves of immigration to Israel in the past century. Two unpublished cases of Ethiopian immigrants are the first reported cases of mycetoma acquired in Ethiopia. The diagnostic and therapeutic challenges along with the epidemiological data emphasize the need of raising the awareness of physicians to this devastating condition even in developed countries.

Background The in vivo demonstration of Demodex infestation is traditionally based on the microscopic identification of Demodex mites, which is time consuming and requires specific equipment and a trained observer. Objective The aim of this study was to describe for the first time the use of polarized-light dermoscopy for the diagnosis of demodicidosis in patients with variable clinical presentations. Methods A total of 72 patients with variable facial eruptions were examined clinically, microscopically, and dermoscopically for the presence of Demodex mites. Results Of the 72 patients, 55 were found to have demodicidosis. In 54 patients, the dermoscopy examination yielded a specific picture consisting of Demodex “tails” and Demodex follicular openings. In patients with an inflammatory variant of demodicidosis, reticular horizontal dilated blood vessels were also visualized. Microscopically, skin scrapings demonstrated Demodex in 52 patients. Overall, the dermoscopy findings showed excellent agreement with the microscopy findings (kappa value 0.86, 95% CI 0.72–0.99, P

Candida albicans is regarded as the major pathogen in yeast-induced onychomycosis. Based on our impression of an increasing prevalence of Candida parapsilosis in this disease, we examined the data of two mycology laboratories in the same geographic location, from 1994 to 1996 in one (centre A) and for 1995 (6 months) in the other (centre B). A total of 954 and 230 toenails and 621 and 190 fingernails, respectively, underwent KOH microscopy and culture studies in each centre. Positive findings were noted in 45 and 65% of the toenails and 44 and 72% of the fingernails, respectively. In the toenails, Candida spp. were found in 22 and 15%, respectively, and in the fingernails, in 77 and 63%, respectively. The most frequent Candida species was C. parapsilosis (39.5% in toenails, 36.7% in fingernails), followed by C. albicans (19.5% in toenails, and 34.4% in fingernails). These results demonstrate a higher frequency of isolation of C. parapsilosis compared with C. albicans in onychomycosis. This might have important therapeutic implications.

Wells' syndrome is a multifaceted dermatosis with a wide morphological spectrum, ranging from characteristic cellulitis-like erythema and wheals to an unusual presentation of vesicles and bullae. We describe a patient in whom Wells' syndrome presented as an insect-bite-like eruption and was associated with underlying mantle-cell lymphoma. We recommend meticulous investigation of patients diagnosed with Wells' syndrome manifesting as an insect-bite-like eruption.

The in vivo demonstration of Demodex infestation is traditionally based on the microscopic identification of Demodex mites, which is time consuming and requires specific equipment and a trained observer.The aim of this study was to describe for the first time the use of polarized-light dermoscopy for the diagnosis of demodicidosis in patients with variable clinical presentations.A total of 72 patients with variable facial eruptions were examined clinically, microscopically, and dermoscopically for the presence of Demodex mites.Of the 72 patients, 55 were found to have demodicidosis. In 54 patients, the dermoscopy examination yielded a specific picture consisting of Demodex "tails" and Demodex follicular openings. In patients with an inflammatory variant of demodicidosis, reticular horizontal dilated blood vessels were also visualized. Microscopically, skin scrapings demonstrated Demodex in 52 patients. Overall, the dermoscopy findings showed excellent agreement with the microscopy findings (kappa value 0.86, 95% CI 0.72–0.99, P0.001). In the remaining 17 patients, there was no evidence of Demodex infestation either microscopically or dermoscopically.The study was not blinded. As there are no standards for the diagnosis of demodicidosis, our results were based on criteria developed by our research group.This is the first description of the specific dermoscopic findings associated with variable clinical presentations of demodicidosis. Dermoscopy may serve as a valuable tool for the real-time validation of Demodex infestation and the evaluation and follow-up of affected patients.

Background The cellular immune system is the most dominant factor in curing acute dermatophytosis. However, the exact immune mechanisms involved in generating this defense are complex and still obscure. The aim of this study was to investigate the fungicidal mechanism of T cells in the normal population versus patients with chronic fungal infections. Methods Thirty patients were included in the study: 15 patients with chronic dermatophytosis and 15 normal healthy patients with a history of acute dermatophytosis. The procedures were performed as follows. 1) Proliferation and cytotoxic activity of lymphocytes cultured with various dermatophytes homogenate such as, Trichophyton rubrum, Trichophyton mentagrophytes and Microsporum gypseum. 2) CD4+ and CD8+ T cells were separated by magnetic beads before culture with fresh spores of either T. mentagrophytes or T. rubrum. 3) Routine histology and ultrastructural study were performed to illustrate the mode of activity of the T cells against the dermatophytes. Results The study showed that both CD4 and CD8 possess cytotoxic activity against dermatophytes. However, the results demonstrated a suppression of lymphocyte proliferation response and a significant lower cytotoxic effect in chronic patients. Ultra structure and histological evaluation of the culture of hyphae with CD4+ or CD8+ T cells showed more prominently destructive effects in the culture of cells that had been obtained from normal population than those of patients with long-lasting fungal infections. Conclusion The study suggests a selective impairment of lymphocyte function against dermatophytes, in patients with chronic dermatophytoses.

In a series of 100 adults with tinea faciei various dermatologic manifestations were mimicked, viz.: discoid lupus erythematosus in 52 patients, lymphocytic infiltration in 15, seborrheic dermatitis in 11, rosacea in 8, contacts dermatitis in 7, polymorphous light eruption in 4 and granuloma faciale in 3. Trichophyton rubrum was isolated in 78% of the respective cases, other isolated organisms being Microsporum canis (13 cases), Trichophyton violaceum in 6, Trichophyton mentagrophytes (asteroides) in 2 and Epidermophyton floccosum in 1 case. In 85% of these patients the nails were also involved by the same agent found in the lesions of the face. On the basis of these observations it is recommended that all adult patients with tinea faciei should undergo a comprehensive mycological investigation to find the primary focus, which may be an infected nail.

Prednisone is a widely used medication in dermatology, particularly in pemphigus patients. Simple objective laboratory methods are suggested for the evaluation of prednisone intake, taking advantage of the similar chemical structure of cortisol and prednisolone. A linear correlation was found between the dose of prednisone, above 40 mg/day, free urinary prednisolone, measured with an radioimmunoassay kit for cortisol that cross-reacts with prednisolone, and 17-hydroxycorticosteroids, measured by Metcalf's method. Approximately 9% of the prednisone administered was recovered as free prednisolone and about 40% as 17-hydroxycorticosteroids. It is suggested that these simple laboratory methods constitute a useful substitute for the more costly, sophisticated methods available at present for determining levels of prednisone and prednisolone.

In a series of 60 patients (42 males, 18 females) with widespread lesions of pityriasis versicolor, 200 mg of oral ketoconazole was administered daily for a period of 24 days. Routine laboratory examinations, including microscopic and Wood’s light examinations, were performed prior to initiation of treatment and twice during the treatment period as well as 3 and 6 months, and 1 and 2 years after completion of treatment. In 95% of the patients the clinical cure was maintained after 3 months but after 6 months it was still present in only 80% and after one year in only 57%. At the end of two years 60% showed relapse of the disorder. In 75% hypopigmented macules persisted after 6 months but without microscopic evidence of the fungus. No side effects were reported. It is evident that oral ketoconazole is effective in maintaining a clinical cure mainly during the first 3 months after treatment. The question as to whether side effects might appear with a more prolonged course of the drug should be given serious consideration before continuation of treatment is contemplated.

A case of mycetoma, with abscess-like lesions which appeared on the right forearm of a 43-year-old male, is briefly reported. A few whitish granules were detected in the oily-like discharge, the same as in the histologic examination. No bone involvement was discovered in X-ray examination. Actinomadura was identified in the culture. A daily dose of 4 g bactrin brought significant improvement to the patients continuing the treatment.

The observation of a 51-year-old male patient with transient acantholytic dermatosis (TAD) is briefly reported. The discrete eruption, composed of erythematous escoriated papules and papulovesicles, moderately itching, was located on the back and chest, more permanent during the summer season. The biopsy revealed suprabasal acantholysis and Darier-like elements. Lesions of pityriasis versicolor, confirmed by microscopic examination and fluorescence in Wood’s light, were intermingled with TAD in the same patient. A topical treatment with selenium sulfide brought TAD lesions to the disappearance in 1 week. Comments are made in relation with the possibility of Malassezia furfur to induce acantholytic phenomena.

Pityriasis rotunda (PR) has been known to affect, almost exclusively, Japanese and South African Bantu, often in association with various systemic diseases. However, the occurrence of PR in Caucasian patients is extremely rare, and has been previously described in only three reports. We hereby report a case of an apparently healthy Caucasian woman from Israel having clinical and histological features characteristic of PR. Pityriasis rotunda (PR) is a rare disorder of keratinization characterized by strikingly well demarcated, perfectly round scaly brownish patches of variable number and diameter located mainly on the trunk and extremities. The exact place of this disorder within the nosology of the cutaneous dermatoses is not yet fully established. However, most authors regard it as a special circumscribed form of acquired ichthyosis with a histological resemblance to ichthyosis vulgaris. For more than half a century following the first description of this disorder in 1906 cases reported were almost exclusively from the Far East, particularly from Japan, or in South African Negroids, with a few cases of West Indian Negroids, usually in association with various debilitating diseases. The first report of a Caucasian patient appeared in the literature in 1966 and since then there have been only two additional reports of PR in Caucasian patients.

During a period of 8 years 300 cases of dermatophytoses involving both hairy areas and the glabrous skin were found to be caused by M. canis. There was scalp involvement in 60%, including 8 infants and 27 adults; most of the adults presented Kerion-like lesions and presented various clinical aspects such as seborrhea capitis, folliculitis and discoid lupus erythematosus. In the 21 patients showing invasion of the beard the clinical manifestations included superficial erythemato-squamous patches with hyperemic slightly elevated margins, folliculitis or abscess-like lesions and Kerion-like lesions. Among the lesions found on the glabrous skin there were unusual aspects of tinea faciei in 19 adults, mimicking lymphocytic infiltration, granuloma faciale or discoid lupus erythematosus. Some of the cases of tinea corporis found in 70 patients also had lesions simulating various other dermatological entities, including erythema multiforme, psoriasiform eruption, pityriasis rosea and seborrheic dermatitis. The hands were invaded in 5 adults patients, with involvement of the finger nails in one. Repeated mycologic examinations were necessary to establish the true etiology in many of these cases.

The leucocyte migration inhibition (LIF) was investigated in 16 patients with Behçet’s disease, 5 while in the active stage of the process, 3 both during relapse and remission, and 8 during remission of symptoms. In all patients skin tests with various antigens and with a needle prick and physiological saline were simultaneously performed. The results indicate a strong correlation between the activity of the disease, skin reactivity and the reactivity of LIF.

The association of HLA antigens with pemphigus in Jewish patients of various ethnic origins was investigated. Of 45 Ashkenazi patients, 31 (68.6%) had A26 (p < 10––5) and 32 (71.7%) had BW38 (p < 10––5). Among the 11 non-Ashkenazi patients, 7 (63.6%) had A26 and only 1 had BW38. The question whether the antigen A26 or BW38 is linked with the disease is discussed. Our findings may suggest that the primary association of pemphigus is with A26. This association may be stronger in Jewish male patients than in females. In view of the recent literature and our results it may be presumed that pemphigus in Jews is associated with antigens of Loci A and DR. No differences between pemphigus vulgaris and pemphigus erythematosus were observed.

Thirty-four psoriatic patients (23 males, 11 females) were found to have skin manifestations of dermatophyte infection. Tinea pedis was observed in 20 cases, tinea cruris in 6 and tinea manuum in 2. T. rubrum was the causative agent in all of these with the exception of 2 cases caused by E. floccosum. Lesions of tinea corporis were found intermingled with psoriatic plaques in various areas of the body skin in 6 patients (4 males, 2 females); T. rubrum was isolated from 5 of these and M. canis from one. Twenty-one of these psoriatic patients also had lesions caused by C. albicans in the toe-webs and interdigital aspects of the fingers, the latter being associated with paronychia in 9 cases. These findings indicate that we should remain aware of the possibility of fungus manifestations in patients with psoriasis, which would not appear to be an exceptional occurrence.