Surveillance of Dermatophytosis in Northeast of Iran (Mashhad) and Review of Published Studies

Dermatophytoses are considered to be one of the major public health problems in the world and are among the most commonly diagnosed skin diseases in Iran. In spite of improved personal hygiene and living environment, dermatophytosis continues to spread and persist. To determine the prevalence of dermatophytosis and their etiologic agents in Mashhad (Iran), five hundred and sixty patients suspected to have fungal infection were studied. Subjects who participated in this study were 330 males and 230 females ranged in age from 4 months to 70 years with a mean age of about 25.5 years. Clinical materials including skin scraping, hair and scalp sample, nail clipping and subungual debris were collected. All of the specimens were assessed by direct examination and culture. Of 560 patients, 166 (29.6 %) had dermatophytosis. The types of tinea according to anatomical areas were as follows: tinea corporis (33.1 %), tinea capitis (32.5 %), tinea manuum (17.5 %), tinea cruris (10.2 %), tinea pedis (5.4 %), tinea unguium (0.6 %) and tinea barbae (0.6 %). Trichophyton verrucosum was the most prevalent species followed by Trichophyton violaceum and Trichophyton mentagrophytes. The prevalence of dermatophytosis in males was higher than in females. Based on a review of published studies from different parts of Iran, there are regional differences in the incidence of dermatophytosis. Epidermophyton floccosum has been the most prevalent species, and Microsporum canis has been isolated less than from the other countries.     

A study of dermatophytosis in South West of Iran (Ahwaz)

Two hundred and seventy nine patients suspected of having fungal lesions were examined. Skin scrapping, hair samples and nail clippings were collected from patients. Direct and culture examinations were performed for all samples. About 115 cases of examined subjects had dermatophytosis. Dermatophytosis occurred mainly in adults males (20–29 years). Tinea cruris (24.3%) was the most common type of dermatophytosis followed by tinea pedis (16.5%), tinea corporis (14.8%), tinea ungium (13%), tinea capitis (11.3%), tinea faciei (11.3%), tinea manuum (7%) and tinea barbae (1.7%). Trichophyton mentagrophytes was the most prevalent species followed by Epidermophyton floccosum.     

<Emphasis Type="Italic">Trichophyton rubrum</Emphasis> Infection Characterized by Majocchi’s Granuloma and Deeper Dermatophytosis: Case Report and Review of Published Literature

Infections caused by Trichophyton rubrum are very common in dermatological disease. It most often appears as superficial cutaneous mycosis, such as tinea manuum, tinea pedis, and tinea corporis. However, deep infection caused by T. rubrum was rarely reported. We describe a case of mixed type of deep infection caused by T. rubrum in a 45-year-old man with no significant immunodeficiency. This patient had a history of onychomycosis on the toenails without regular treatment for nearly 6 years. And, he had erythema, papule, and nodules on the submandibular area, neck, and chest for almost 1 year. After treated with intravenous infusion of cefotiam for 2 weeks, the lesion aggravated. The fungal direct microscopic examination of pyogenic fluid was positive, and the fungal cultures that produced reddish-brown and yellow pigment showed cottony, wooly, and white colony. After the DNA sequencing, it was identified as T. rubrum. We gave the patient oral terbinafine 250 mg per day and bifonazole cream for external use. Six months later, the patient’s skin lesion was disappeared, and healthy nail growth was seen in two-thirds of nail bed. The terbinafine is effective against deep infection caused by T. rubrum.     

Update in Antifungal Therapy of Dermatophytosis

Treatment of dermatophyte infection involves primarily oral and/or topical formulations of azoles or allylamines, particularly itraconazole and terbinafine. Topical medications applied once or twice daily are the primary treatment indicated for tinea corporis/cruris, and tinea pedis/manuum. Use of oral antifungals may be practical where the tinea involvement is extensive or chronic, or where application of a topical is not feasible. For tinea unguium (onychomycosis) and tinea capitis, oral therapies are the primary treatments provided. Recently, topical amorolfine and ciclopirox formulations have been approved for use in milder onychomycosis cases, and their role in the treatment of the different clinical forms of onychomycosis is currently being defined. Relapse of infection remains a problem, particularly with tinea pedis/unguium. Appropriate follow-up duration and education of patients on proper foot hygiene are also important components in providing effective therapy.     

Analysis of Dermatomycoses in Lanzhou District of Northwestern China

The skin mycoses, perticularly dermatophytoses, in Lanzhou district, Northwestern China, was investigated during July 2002–June 2003. The specimens from patients suspected of having dermatomycoses were examined microscopically in KOH preparations and cultured on Sabouraud dextrose agar (SDA). Among 1443 suspected cases, 594 were KOH positive and 221 cultures of fungi were isolated. The most frequently isolated fungi were Trichophyton rubrum (43.9%) Trichophyton mentagrophytes (29.4%) and Candida species (14.0%). The frequency of tinea pedis, onychomycosis and tinea manuum were 38.7, 27.8 and 13.5%, respectively. In Lanzhou district, tinea pedis is the most commonly seen dermatophytoses, and T. rubrum is the most frequent etiologic agent.     

New data on the epidemiology of Tinea cruris in Israel

Among 250 patients with tinea cruris (160 males, 90 females) lesions of both tinea pedis and tinea unguium were found in 221 and lesions of only tinea pedis in another 25. The four children were free of associated dermatophytic lesions. The predominant causative agent was T. rubrum, which was also found to be responsible for the hairy area invasion of the beard and pubis in 12 patients and for the widespread lesions of tinea corporis in 10 patients with lymphoma. None of these patients had noticed the discrete nail and foot involvement. It is therefore recommended that all patients with tinea cruris be subjected to careful examination of all possible mycotic foci, particularly the feet and nails.     

特比萘芬治疗顽固性手、足癣的临床疗效及安全性评价

目的评价特比萘芬治疗顽固性手、足癣的临床疗效及安全性。方法将120例患者随机分为实验组和对照组,实验组口服特比萘芬250mg,1次/d,联合外用特比萘芬乳膏,2次/d,连续3周;对照组患者仅外用特比萘芬乳膏2次/d,连续3周。停药2周后评价最终疗效和不良反应,停药4周后观察复发率。结果停药2周后,实验组患者的临床有效率为95%,真菌学清除率为95%,不良反应发生率为5%（主要为胃肠道反应）;对照组患者的临床有效率为40%,真菌学清除率为75%。停药4周后,实验组患者未见复发,对照组患者复发率为20%。结论口服特比萘芬联合外用特比萘芬乳膏治疗顽固性手、足癣是安全、有效的。     

Studies in the Epidemiology of Tinea Pedis. IX: Tinea Pedis and Erythrasma in New Patients at a Chiropody Clinic

The feet of 259 new patients at a chiropody clinic were examined for tinea pedis, onychomycosis, and erythrasma: 23% of men and 4% of women were infected by dermatophytes, and the nails of seven males were infected by non-dermatophytes. Of 200 patients examined under Wood''s light 37% showed the coral-red fluorescence of erythrasma.Of the 259 patients, 9.7% were infected by Trichophyton interdigitale, 2.7% by T. rubrum, and 1.5% by Epidermophyton floccosum. Reasons are given, based on the method of selection of the patients, for supposing that T. interdigitale is still the dominant cause of tinea pedis in the population at large, despite figures from dermatological clinics suggesting the dominance of T. rubrum. The high incidence of infection in males compared with females corresponds with similar findings in school-children.     

Prevalence of Dermatophytoses in the Zarqa District of Jordan

A total of 350 clinically suspected cases of dermatomycoses were examined for causative fungi during July 1997 to September 1998. Mycotic infection was demonstrable by microscopy and culture in 199 (56.8%) cases. The most common superficial mycotic infections were tinea pedis (35.2%) followed by tinea capitis (23.1%), tinea unguium (21.6%) and tinea corporis (10.6%). Most of the infected patients were 1–9, 20–29 and 30–39 years old. Men were mainly infected with tinea cruris and tinea pedis, while women were infected with tinea pedis, tinea unguium and tinea capitis. The frequencies of etiological agents isolated from patients were as follows: Trichophyton mentagrophytes var. interdigitale (32.7%), T. rubrum (28.6%), Epidermophyton floccosum (20.1%), Microsporum canis (11.1%), T.schoenleinii (4%), T.verrucosum (2%), T.violaceum (1%), and M. gypseum (0.5%). The number of infections varied with the seasons. The highest number of cases of tinea pedis and tinea cruris occurred in the summer months, while tinea capitis, tinea corporis and tinea unguium occurred in the spring and winter months. This revised version was published online in June 2006 with corrections to the Cover Date.     

Epidemiology of Dermatophytoses in an Area South of Tehran,Iran

Dermatophyte infections have been considered to be a major public health problem in many parts of the world. The aim of this study was to identify the etiological and epidemiological factors of dermatophyte infections in an area south of Tehran. A total of 1254 patients suspected to have dermatophytic lesions were examined over a period of three years (1999-2001). Material collected from skin, hair, and nails was submitted to direct microscopic examination using KOH, cultured in Sabouraud dextrose agar and microscopically examined for colony morphology, in order to the identify the 169 dermatophytes isolated. The prevalence of dermatophytoses was 13.5% (95% CI: 11.7-15.5%). Their incidence was 10.6 per 100,000 person-years (95% CI: 8.5-13.2). Epiderophyton floccosum was the most frequent dermatophyte isolated (31.4%) followed by Trichophyton rubrum (18.3%), T. mentegrophytes (17.2%), T. violaceum (16.6%), Microsporum canis (6.5%), T. verrucosum (4.7%) and M. gypseum (4.1%). Epidermophytes floccosum was found to be the most common isolated dermatophyte in age groups 20-29 (30.2%). Tinea corporis (31.4%) was the most common type of infection, followed by tinea cruris (20.7%), tinea manuum (15.4%), tinea capitis (12.4%), tinea pedis (10.6%), tinea faciei (7.1%), and tinea unguium (2.4%). The frequency rate of all of the types of tinea was higher in males than in females. The anthrophilic species E. floccosum was the most common dermatophyte as a causative agent of tinea. The most prevalent fungal infection was tinea corporis caused by E. floccosum.     

Dermatology for the practicing allergist: Tinea pedis and its complications

Tinea pedis is a chronic fungal infection of the feet, very often observed in patients who are immuno-suppressed or have diabetes mellitus. The practicing allergist may be called upon to treat this disease for various reasons. Sometimes tinea infection may be mistaken for atopic dermatitis or allergic eczema. In other patients, tinea pedis may complicate allergy and asthma and may contribute to refractory atopic disease. Patients with recurrent cellulitis may be referred to the allergist/immunologist for an immune evaluation and discovered to have tinea pedis as a predisposing factor. From a molecular standpoint, superficial fungal infections may induce a type2 T helper cell response (Th2) that can aggravate atopy. Th2 cytokines may induce eosinophil recruitment and immunoglobulin E (IgE) class switching by B cells, thereby leading to exacerbation of atopic conditions. Three groups of fungal pathogens, referred to as dermatophytes, have been shown to cause tinea pedis: Trychophyton sp, Epidermophyton sp, and Microsporum sp. The disease manifests as a pruritic, erythematous, scaly eruption on the foot and depending on its location, three variants have been described: interdigital type, moccasin type, and vesiculobullous type. Tinea pedis may be associated with recurrent cellulitis, as the fungal pathogens provide a portal for bacterial invasion of subcutaneous tissues. In some cases of refractory asthma, treatment of the associated tinea pedis infection may induce remission in airway disease. Very often, protracted topical and/or oral antifungal agents are required to treat this often frustrating and morbid disease. An evaluation for underlying immuno-suppression or diabetes may be indicated in patients with refractory disease.     

趾间型足癣患者细菌菌种分布特征

目的了解趾间型足癣患者趾间和健康志愿者趾间细菌菌种分布特征。方法对37例经临床和真菌镜检确诊的趾间型足癣患者的趾间进行细菌培养,然后给予1%联苯苄唑霜1次/d外用治疗4周,在治疗后的第1、2、4周分别对趾间再进行细菌培养。33例健康志愿者作为对照。结果健康志愿者趾间细菌培养葡萄球菌属占92.5%,其中表皮葡萄球菌占32.5%,未分离到金黄色葡萄球菌。趾间型足癣患者细菌培养葡萄球菌属占74.4%,其中金黄色葡萄球菌占27.9%,表皮葡萄球菌仅占2.3%,还分离到化脓性链球菌、粪肠球菌、屎肠球菌、奇异变形杆菌、铜绿假单胞菌等。经过4周的外用联苯苄唑霜治疗,金黄色葡萄球菌消失,表皮葡萄球菌又成为优势菌（37.5%）。结论趾间型足癣患者趾间金黄色葡萄球菌的分离率明显高,此乃足癣继发细菌感染的主要致病菌,因此积极治疗足癣对预防足癣合并症有非常重要的意义。     

东南沿海部队皮肤浅部真菌病的调查研究

目的了解东南沿海部队官兵近年真菌菌种构成情况及调查浅部真菌病非高发季节的患病率。方法于11月对浙江地区和福建地区某部队官兵共324人进行浅部真菌病患病情况调查,通过临床检查确定皮肤病种类和感染人(次),对于临床诊断为浅部真菌病的官兵进行真菌镜检证实后明确诊断,并留菌种进行真菌培养。结果真菌感染性疾病患病率为55.2%(324人中179人发病),其中手足癣158人次(48.8%),体股癣35人次(10.8%),花斑癣24人次(7.4%),马拉色菌毛囊炎18人次(5.6%),甲癣5人次(1.5%)。真菌镜检阳性率为76.36%,首位致病菌为红色毛癣菌71株,占84.5%。结论部队尤其是亚热带地区部队,浅部真菌病的患病率较高,不同驻地官兵患皮肤浅部真菌病有差异,而服役年限及兵源与患皮肤浅部真菌病之间无显著差异。     

In vivo fungicidal effect of KP-103 in a guinea pig model of interdigital tinea pedis determined by using a new method for removing the antimycotic carryover effect

We developed a new technique for culture study that successfully recovers fungi from drug-treated skin tissues, in which tissue specimens were homogenized, dialyzed against water, digested with trypsin, and then washed with PBS, to eliminate the drug that remaining in the skin tissue specimens. With this modified culture method, we reevaluated the efficacy of KP-103, neticonazole, and lanoconazole in a guinea pig interdigital tinea pedis model. Guinea pigs with tinea pedis were topically treated with a 1% solution of KP-103 or a reference drug once a day for 10 consecutive days. Five days after the last treatment, left and right feet were subjected to culture study by the conventional and modified recovery culture methods, respectively. One hundred percent (20/20) of lanoconazole-treated feet were judged as culture-negative by the conventional culture method, but 85% (17/20) of the feet were shown to be culture-positive when the modified recovery culture method was used. On the other hand, KP-103 achieved high rates of culture-negative rates, 95% (19/20) and 85% (17/20), in both conventional and modified culture methods, respectively. Furthermore, on day-30 posttreatment, KP-103 sterilized 14 of the 20 infected feet, whereas neticonazole and lanoconazole were not effective even in reducing fungal burden. KP-103 proved to be highly effective in achieving mycological cure and preventing relapse against tinea pedis presumably because of its good bioavailability in the skin based on its low keratin-affinity, along with its potent antifungal activity.     

Epidemiologic study of dermatophyte infections in Nigeria (clinical survey and laboratory investigations)

The commonest dermatophyte infection among the referred dermatology cases in Nigeria is tinea pedis, whereas among the surveyed population of school children, the commonest fungal infection was tinea capitis.It was found that the most ubiquitcus causative organism for tinea pedis was E. fluccosum, that for tinea capitis was M. audouinii, while that for tinea corporis was T. soudanese.The source of infection of tinea capitis among the school children was found to be most likely the local barber who serviced the schools in all the villages, and this might explain the high incidence rate of T. soudanese in tinea capitis. Tinea pedis infection is believed to be highly favoured by the wearing of shoes among the senior students. Animals were not a major source of transmission of dermatophytes in Nigeria.No new species of dermatophytes has been identified among the cultured organisms.     

A study of 3891 cases of mycoses in the tropics.

4103 cases suspected of mycoses were analysed as to sex, age and site of disease and 3891 were proved cases. This group formed 50% of total mycoses or 13-93% of all dermatoses recorded in the Government General Hospital, Madras, during the period of study. There were 66-26% adult female, 27-6% adult male and 6-14% were below 13 years. Dermatophytoses were found in 73-5%; the other common diseases were tinea versicolor (17-68%) and candidiasis (12-43%). Multiple sites of involvement or more than 1 disease in the same individual were mostly observed. The incidence of piedra (0-1%) and deep mycoses (0-156%) was very low. Mycetoma was the common disease (5/6) in deep mycoses. In dermatophytoses, tinea corporis (49-71%) and tinea cruris (47-85%) commonest; tinea axillaris (3-42%), tinea capitis (1-72%) and tinea barbae (1-29%) were less common. The incidence of tinea manuum, tinea pedis and tinea unguium was similar (4-97%-6-38%). High temperature and humidity were related to the higher incidence of tinea corporis, tinea cruris and tinea versicolor. Mainly children suffered from tinea capitis. All other mycoses were commonly found in adults between 2nd and 3rd decades. In all mycoses but candidiasis, female predominated. Cutaneous candidiasis was mainly a problem of housewives. Among the dermatophytes Trichophyton violaceum was predominant (33-7%) followed by T. rubrum (32-6%). Trichophyton schoenleinii and M. gypseum were rarely isolated. From mycetoma, Madurella mycetomii, Nocardia braziliensis, N. asteroides and Actinomadura spp. were isolated. Demonstration of Cryptococcus laurentii in 1 case is reported in this area for the first time.     

Griseofulvin in the treatment of dermatomycoses and onychomycoses produced by dermatophytes of the Trichophyton group

Summary Based on observations on the therapy of 128 patients affected with tinea unguium, tinea manus et pedis, tinea granulomatosa nodularis (Granuloma Majocchi), tinea cruris, tinea corporis, tinea barbae and tinea capitis due to infection with dermatophytes of theTrichophyton group, determinations were made for the absolute and relative indication of griseofulvin in the treatment of these mycoses. For each affection, comparisons were made between the therapeutic results obtained by combined therapy with oral griseofulvin (uniform daily dose 1 g for each case) and local therapy with 1 % water solution organic dyes, coal tar on the one hand, and mere local therapy as described above, on the other. For treatment, griseofulvin of different production was available: British Grisovin, Likuden and Likuden M from West-Germany, and Griseofulvin produced in the German Democratic Republic. No essential differences were found in the therapeutic effect of the individual preparations, the tolerance, however, was found to be best with Likuden. On the basis of comparisons made for the results of the individual methods of treatment, griseofulvin therapy was found to be an absolute indication of the mycotic diseases as follows: tinea capitis, tinea cruris follicularis trichophytica and tinea unguium. A relative indication was found to be tinea corporis, tinea barbae, tinea cruris, and tinea manus et pedis.All patients were subjected to microscopic and culture examination. The frequency of the individual dermatophytes was as follows:Trichophyton rubrum in 56 cases,Trichophyton verrucosum in 19 cases,Trichophyton mentagrophytes in 16 cases, andTrichophyton violaceum in 1 case. Thirty six cases showed negative cultures.In conclusion, the author recommends individual selection of patients for the griseofulvin therapy.     

Fungal infection of the feet in soccer players and non-athlete individuals

This study was conducted to evaluate the occurrence of mycoses affecting the feet of soccer players and to compare this results with those in non-athlete individuals of the same age and sex. Initial evaluation consisted of a dermatological examination of the foot in 22 Chinese athletes, 83 Brazilian athletes and 24 Brazilian non-athletes. Scales of plantar skin, interdigital and subungual areas of the foot were collected for mycological examination (direct and culture). Nail clippings were obtained for histopathologic analysis. Tinea pedis was diagnosed more frequently among the non-athlete individuals. None of the Chinese athletes had tinea pedis alone. However, in this group onychomycosis was frequently higher when compared to the other groups. The fungal microbiota comprised Trichophyton rubrum (40%), Trichophyton mentagrophytes (36.4%) and Candida spp (20%). Candida spp was isolated only from Brazilian athletes. Results obtained with KOH wet mounts agreed with the results obtained in culture and with histopathologic examinations (50.5% vs 40.9%). The frequency of tinea pedis among soccer players was lower than the other groups in this study, possibly due to health education and professional feet care.     

足癣患者治疗现状调查

目的了解中国足癣患者的治疗现状,加强临床医生对相关诊治指南推荐方案的认知和理解。方法中国医师协会皮肤科医师分会组织全国9家医院进行中国足癣患者治疗现状问卷调查。结果共收集到问卷690份,结果显示我国足癣患者大多数选择自行购买外用抗真菌药物治疗,最常选用的外用药物为咪唑类药物,往往以瘙痒和／或皮疹消失作为停止治疗的依据,治疗最长时间中位数为2周,在治疗足癣的疗程上显示出明显不足。足癣患者常合并甲真菌病等其他皮肤癣菌病,同时其家庭成员患病率也较高,在治疗足癣患者的同时,应积极治疗其合并的其他皮肤癣菌病,也应同时对患者家庭成员进行治疗。结论本研究对更加有针对性地制定合理足癣预防和治疗方案并加强患者宣教具有重要作用。     

Predictors of relapse or maintenance of response in pediatric and adult patients with attention-deficit/hyperactivity disorder following discontinuation of long-term treatment with atomoxetine

We identified relapse/maintenance-of-response (MOR) predictors following discontinuation of long-term atomoxetine treatment in pediatric and adult patients with attention-deficit/hyperactivity disorder (ADHD) and assessed correlations between ADHD symptoms and quality of life (QoL). Post hoc analyses of data from two randomized, double-blind, placebo-controlled, phase 3 withdrawal studies in patients with ADHD meeting predefined response criteria before randomization. Study 1: patients (N = 163; 6–15 years) received atomoxetine (1.2–1.8 mg/kg/day) for 1 year, followed by randomization to atomoxetine (n = 81) or placebo (n = 82) for 6 months. Study 2: patients (N = 524; 18–50 years) received atomoxetine (80–100 mg/day) for ~6 months, followed by randomization to atomoxetine (n = 266) or placebo (n = 258) for ~6 months. Placebo patients were used for the analyses. Relapse: ≥50% worsening of prerandomization improvement in ADHD symptoms and ≥2 level severity increase on the Clinical Global Impression-Severity (CGI-S) scale at 2 consecutive visits; MOR: retaining ≥75% of prerandomization symptom improvement and CGI-S ≤ 2 at all visits (study 1); retaining ≥70% of prerandomization symptom improvement and CGI-S ≤ 3 at all visits (study 2). In adults, statistically significantly (P ≤ .05) increased likelihood of relapse was associated with prerandomization presence of Conners’ Adult Attention-Deficit/Hyperactivity Disorder Rating Scale-Investigator-Rated:Screening Version (CAARS-Inv:SV) items “difficulty awaiting turn” and “careless mistakes.” In pediatric patients, less MOR was associated with prerandomization presence of ADHD Rating Scale-IV-Parent Version Investigator-Rated item “does not listen”; in adults, less MOR was associated with prerandomization presence of CAARS-Inv:SV items “loses things” and “difficulty awaiting turn.” Changes in patients’ QoL after withdrawal from atomoxetine moderately correlated with changes in ADHD symptoms in pediatric patients and mildly in adults.