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Management of subcutaneous phaeohyphomycosis via Mohs micrographic surgery
2360
3678
Hypersensitivity reaction to Sporothrix schenkii: Erythema nodosum associated with sporotrichosis Francine Papaiordanou, MD, Prof Rubem David Azulay Dermatology Institute, Rio de Janeiro, Brazil; Bruno Rebelo Lages da Silveira, MD, Prof Rubem David Azulay Dermatology Institute Rio de Janeiro, Brazil; Erika Ara ujo Machado, MD, Prof Rubem David Azulay Dermatology Institute Rio de Janeiro, Brazil; Luna Azulay Abulafia, MD, PhD, Prof Rubem David Azulay Dermatology Institute, Rio de Janeiro, Brazil Since 1998, Rio de Janeiro undergoes an epidemic of sporotrichosis transmitted by cats and its incidence rates remain high, so far. The disease may evolve with different clinical presentations and, although lymphocutaneous is the most prevalent one, the disease can have unusual manifestations in some patients, fact that makes it harder to be diagnosed. The current paper reports an atypical case of sporotrichosis associated with erythema nodosum diagnosed at the Dermatology Clinic of Santa Casa da Misericordia of Rio de Janeiro (Prof Rubem David Azulay Dermatology Institute).
Malassezia infections—Management with pulsed oral ketoconazole F. William Danby, MD, Geisel School of Medicine at Dartmouth, Manchester, NH, United States Malassezia folliculitis, a common mimic of acne and folliculitis, is caused by species of the yeast Malassezia, the cause of tinea versicolor. Present in over 65% of acne papules, Malassezia is a significant part of the microbiome. Immune reaction to this yeast, especially in the scalp, often causes intense itch. Usually undiagnosed, this chronic itch is treated safely and effectively with ketoconazole. We compiled data on a three month cross section (Sept-Nov, 2014) of patients seen in a general dermatology practice treated for Malassezia infections with oral ketoconazole. Of the 151 patients, over half cleared or showed significant improvement, while only 8% reported no change. This inflammatory reaction presents as dozens to hundreds of pinhead to 2-mm folliculopapules and folliculopustules scattered over the acne area (face, chest, shoulders and back), and is often mistaken for acne. Treating acne patients with an antibiotic, ignoring the underlying yeast, creates an opportunistic environment for overgrowth of the Malassezia, similar to the relationship between broad spectrum antibiotics and vulvovaginal ‘‘yeast infections.’’ In our cohort, 51% of patients had been on a recent course of antibiotics or corticosteroids. Diagnosis is clinical. Culture and biopsy confirmation are of limited use. Koch postulates are rendered incapable of proof because of the ubiquity of the organism. The best way to confirm the clinical diagnosis is with a trial of therapy. Pulsed oral ketoconazole for this yeast overgrowth is dosed as two 200 mg tablets (400 mg) weekly over an eight week course. The highly lipophilic nature of the ketoconazole dovetails with the yeast’s metabolic dependence upon sebum. The Malassezia cell wall becomes unable to ‘hold on’ to the ductal keratinocytes, the yeast is pushed out onto the skin’s surface, and washed away. Patients take the medicine with a swallow of water on an empty stomach, followed by a spoonful of peanut butter (or lipid equivalent) to aid in absorption and to reduce the possibility of GI upset. Oral ketoconazole has proven superior to topical antifungals because the topicals do not penetrate the follicle to the depth required. It is also more cost effective than itraconazole. Oral ketoconazole, never FDA-indicated for use against Malassezia, is not FDA-restricted from ‘off label’ use. FDA files show no serious adverse events recorded at this dose. Further investigation of this off-label use of ketoconazole is warranted.
Commercial support: None identified.
Commercial support: None identified.
2374 Management of subcutaneous phaeohyphomycosis via Mohs micrographic surgery Kara Yakish, MD, Geisinger Medical Center, Danville, PA, United States; Christen Mowad, MD, Geisinger Medical Center, Danville, PA, United States; Victor James Marks, MD, Geisinger Medical Center, Danville, PA, United States; Tammie Ferringer, MD, Geisinger Medical Center, Danville, PA, United States
3156 Investigation of the effects of nano- to micro-ampere ranged alternating current stimulation on the growth of Trichophyton rubrum: A pilot study Joonsoo Park, MD, PhD, Catholic University of Daegu, South Korea; Hyunjung Kwon, MD, Catholic University of Daegu, South Korea Background: Fungi are eukaryotic microorganisms including yeast and molds. There have been a lot of researches on modifying the growth of bacterial growth but only few on fungal growth. However, microcurrent electricity could have stimulatory effect on the fungal growth. Objective: This study aims to investigate the effects of microcurrent electric stimulation on the growth of Trichophyton rubrum. Materials and methods: Standard sized inoculums of T rubrum derived from a spore suspension were applied to potato dextrose cornmeal agar (PDACC) plates, which was then gently withdrawn with a sterile pipette and applied to twelve PDACC plates with a sterile spreader. Twelve Petri dishes were divided into 4 groups. The given amperage of electric current was 500nA, 2A, 4A in group A, B, C and no electric current was given in group D.
Background: Phaeohyphomycosis (PHM) is a term describing a cohort of infections caused by hyphae-forming dematiaceous fungi. PHM infections can be categorized as superficial, cutaneous, subcutaneous or systemic, and management options include excision and/or prolonged systemic antifungal agents. Treatment of subcutaneous PHM is typically surgical; however, guidelines using prospective data for surgical margin recommendations are lacking and recurrence after excision of clinically involved tissue has been reported. We present a case of subcutaneous PHM managed via Mohs micrographic surgery (MMS). Case description: A 92-year-old male presented with painful skin changes of the right knee that began two months prior. The patient described a history of repeated trauma to the affected site from recurrent kneeling, as the patient is an active farmer and performs machine repair work. No systemic symptoms concerning for infection were reported. Physical examination of the right knee revealed a large irregular, somewhat fluctuant pink plaque with serosanguinous drainage on gentle pressure. The overall clinical picture was concerning for infection. Punch biopsies were performed. Histopathologic evaluation favored PHM, which was confirmed via fungal tissue culture (Fonsecaea pedrosoi). After discussion of management options, the patient elected treatment via MMS. After MMS guided margin control, Mohs blocks were sent for routine histopathologic evaluation confirming surgical cure. The patient, now nearly one year status post MMS in the management of subcutaneous PHM, remains without signs and symptoms concerning for persistent or disseminated infection.
Conclusion: The lower intensity of electric current was supplied, the faster fungal growth was observed in the amperage range used in this study. On the basis of this pilot study, further studies with larger sample size, various fungal species, and various intensities of electric stimulation should be carried out.
Discussion: Although PHM can be managed with prolonged systemic antifungal agents, this is usually only necessary in systemic disease or those who are concomitantly immunosuppressed. Detailed guidelines for surgical treatment are not clearly defined. Additionally, reports of recurrent subcutaneous PHM after excision of visibly affected tissue have been reported. MMS offers margin analysis at the time of excision and can be useful in sites where preservation of uninvolved tissue is preferred. Conclusions: MMS provides an alternative surgical option to wide local excision in the management of subcutaneous PHM.
Commercial support: None identified.
Commercial support: None identified.
Results: In the firth 48 hours, only 500nA and 2A exposed fungus appeared colonies, which of 500nA were denser. 4A exposed plates showed a barely visible film of fungus after 96 hours of incubation. Fungal growth became visible after 144 hours in the control group.
MAY 2016
J AM ACAD DERMATOL
AB159
3678
Hypersensitivity reaction to Sporothrix schenkii: Erythema nodosum associated with sporotrichosis Francine Papaiordanou, MD, Prof Rubem David Azulay Dermatology Institute, Rio de Janeiro, Brazil; Bruno Rebelo Lages da Silveira, MD, Prof Rubem David Azulay Dermatology Institute Rio de Janeiro, Brazil; Erika Ara ujo Machado, MD, Prof Rubem David Azulay Dermatology Institute Rio de Janeiro, Brazil; Luna Azulay Abulafia, MD, PhD, Prof Rubem David Azulay Dermatology Institute, Rio de Janeiro, Brazil Since 1998, Rio de Janeiro undergoes an epidemic of sporotrichosis transmitted by cats and its incidence rates remain high, so far. The disease may evolve with different clinical presentations and, although lymphocutaneous is the most prevalent one, the disease can have unusual manifestations in some patients, fact that makes it harder to be diagnosed. The current paper reports an atypical case of sporotrichosis associated with erythema nodosum diagnosed at the Dermatology Clinic of Santa Casa da Misericordia of Rio de Janeiro (Prof Rubem David Azulay Dermatology Institute).
Malassezia infections—Management with pulsed oral ketoconazole F. William Danby, MD, Geisel School of Medicine at Dartmouth, Manchester, NH, United States Malassezia folliculitis, a common mimic of acne and folliculitis, is caused by species of the yeast Malassezia, the cause of tinea versicolor. Present in over 65% of acne papules, Malassezia is a significant part of the microbiome. Immune reaction to this yeast, especially in the scalp, often causes intense itch. Usually undiagnosed, this chronic itch is treated safely and effectively with ketoconazole. We compiled data on a three month cross section (Sept-Nov, 2014) of patients seen in a general dermatology practice treated for Malassezia infections with oral ketoconazole. Of the 151 patients, over half cleared or showed significant improvement, while only 8% reported no change. This inflammatory reaction presents as dozens to hundreds of pinhead to 2-mm folliculopapules and folliculopustules scattered over the acne area (face, chest, shoulders and back), and is often mistaken for acne. Treating acne patients with an antibiotic, ignoring the underlying yeast, creates an opportunistic environment for overgrowth of the Malassezia, similar to the relationship between broad spectrum antibiotics and vulvovaginal ‘‘yeast infections.’’ In our cohort, 51% of patients had been on a recent course of antibiotics or corticosteroids. Diagnosis is clinical. Culture and biopsy confirmation are of limited use. Koch postulates are rendered incapable of proof because of the ubiquity of the organism. The best way to confirm the clinical diagnosis is with a trial of therapy. Pulsed oral ketoconazole for this yeast overgrowth is dosed as two 200 mg tablets (400 mg) weekly over an eight week course. The highly lipophilic nature of the ketoconazole dovetails with the yeast’s metabolic dependence upon sebum. The Malassezia cell wall becomes unable to ‘hold on’ to the ductal keratinocytes, the yeast is pushed out onto the skin’s surface, and washed away. Patients take the medicine with a swallow of water on an empty stomach, followed by a spoonful of peanut butter (or lipid equivalent) to aid in absorption and to reduce the possibility of GI upset. Oral ketoconazole has proven superior to topical antifungals because the topicals do not penetrate the follicle to the depth required. It is also more cost effective than itraconazole. Oral ketoconazole, never FDA-indicated for use against Malassezia, is not FDA-restricted from ‘off label’ use. FDA files show no serious adverse events recorded at this dose. Further investigation of this off-label use of ketoconazole is warranted.
Commercial support: None identified.
Commercial support: None identified.
2374 Management of subcutaneous phaeohyphomycosis via Mohs micrographic surgery Kara Yakish, MD, Geisinger Medical Center, Danville, PA, United States; Christen Mowad, MD, Geisinger Medical Center, Danville, PA, United States; Victor James Marks, MD, Geisinger Medical Center, Danville, PA, United States; Tammie Ferringer, MD, Geisinger Medical Center, Danville, PA, United States
3156 Investigation of the effects of nano- to micro-ampere ranged alternating current stimulation on the growth of Trichophyton rubrum: A pilot study Joonsoo Park, MD, PhD, Catholic University of Daegu, South Korea; Hyunjung Kwon, MD, Catholic University of Daegu, South Korea Background: Fungi are eukaryotic microorganisms including yeast and molds. There have been a lot of researches on modifying the growth of bacterial growth but only few on fungal growth. However, microcurrent electricity could have stimulatory effect on the fungal growth. Objective: This study aims to investigate the effects of microcurrent electric stimulation on the growth of Trichophyton rubrum. Materials and methods: Standard sized inoculums of T rubrum derived from a spore suspension were applied to potato dextrose cornmeal agar (PDACC) plates, which was then gently withdrawn with a sterile pipette and applied to twelve PDACC plates with a sterile spreader. Twelve Petri dishes were divided into 4 groups. The given amperage of electric current was 500nA, 2A, 4A in group A, B, C and no electric current was given in group D.
Background: Phaeohyphomycosis (PHM) is a term describing a cohort of infections caused by hyphae-forming dematiaceous fungi. PHM infections can be categorized as superficial, cutaneous, subcutaneous or systemic, and management options include excision and/or prolonged systemic antifungal agents. Treatment of subcutaneous PHM is typically surgical; however, guidelines using prospective data for surgical margin recommendations are lacking and recurrence after excision of clinically involved tissue has been reported. We present a case of subcutaneous PHM managed via Mohs micrographic surgery (MMS). Case description: A 92-year-old male presented with painful skin changes of the right knee that began two months prior. The patient described a history of repeated trauma to the affected site from recurrent kneeling, as the patient is an active farmer and performs machine repair work. No systemic symptoms concerning for infection were reported. Physical examination of the right knee revealed a large irregular, somewhat fluctuant pink plaque with serosanguinous drainage on gentle pressure. The overall clinical picture was concerning for infection. Punch biopsies were performed. Histopathologic evaluation favored PHM, which was confirmed via fungal tissue culture (Fonsecaea pedrosoi). After discussion of management options, the patient elected treatment via MMS. After MMS guided margin control, Mohs blocks were sent for routine histopathologic evaluation confirming surgical cure. The patient, now nearly one year status post MMS in the management of subcutaneous PHM, remains without signs and symptoms concerning for persistent or disseminated infection.
Conclusion: The lower intensity of electric current was supplied, the faster fungal growth was observed in the amperage range used in this study. On the basis of this pilot study, further studies with larger sample size, various fungal species, and various intensities of electric stimulation should be carried out.
Discussion: Although PHM can be managed with prolonged systemic antifungal agents, this is usually only necessary in systemic disease or those who are concomitantly immunosuppressed. Detailed guidelines for surgical treatment are not clearly defined. Additionally, reports of recurrent subcutaneous PHM after excision of visibly affected tissue have been reported. MMS offers margin analysis at the time of excision and can be useful in sites where preservation of uninvolved tissue is preferred. Conclusions: MMS provides an alternative surgical option to wide local excision in the management of subcutaneous PHM.
Commercial support: None identified.
Commercial support: None identified.
Results: In the firth 48 hours, only 500nA and 2A exposed fungus appeared colonies, which of 500nA were denser. 4A exposed plates showed a barely visible film of fungus after 96 hours of incubation. Fungal growth became visible after 144 hours in the control group.
MAY 2016
J AM ACAD DERMATOL
AB159