The rope sign: a case of interstitial granulomatous dermatitis with arthritis

Interstitial granulomatous dermatitis with arthritis (IGDA), also known as Ackerman's syndrome, is a rare cutaneous disease classically characterized by the triad of cutaneous cords, a typical histologic infiltrate mainly constituted by histiocytes and arthritis/connective tissue disease. Here we report the case of IGDA with the typical clinical and histological features in a patient affected by lupus erythematosus. In this article we underline that IGDA may have a variety of different clinical and histological features. The rope sign is typical but infrequent, while histology is usually characteristic and shows a dermal inflammatory infiltrate, with a predominance of histiocytes, localized interstitially and in a palisaded array between collagen fibres, that show signs of degeneration. Clinical and histological differential diagnoses are discussed.

Relapses of onychomycosis after successful treatment with systemic antifungals: a three-year follow-up

BACKGROUND

Data about relapses of onychomycosis after treatment with the new systemic antifungals vary among the different studies, with figures ranging from 3 to 20% for terbinafine and from 21 to 27% for itraconazole, depending on the follow-up duration.

OBJECTIVE

To determine the prevalence of relapses of onychomycosis cured by terbinafine compared with that of onychomycosis cured by itraconazole.

METHODS

We followed up 47 patients whose toenail onychomycosis had been mycologically cured in an open randomized study comparing intermittent itraconazole treatment with continuous terbinafine treatment and intermittent terbinafine therapy. Patients were examined every 3 months for up to 3 years after the end of therapy. At each visit clinical and mycologic (direct microscopy and cultures) evaluations were performed.

RESULTS

Eight of the 36 patients (22.2%) who completed the study had a relapse of onychomycosis during the follow-up period, including 2 patients of the terbinafine 250 mg group, 2 patients of the terbinafine 500 mg group and 4 patients in the itraconazole 400 mg group. As the original infection, the relapse was caused in all cases by Trichophyton rubrum.

CONCLUSIONS

This study shows that 22.2% of patients with onychomycosis successfully treated with systemic antifungals experienced a relapse. The relapse rate increased from 8. 3% at month 12 to 19.4% at month 24 and to 22.2% at month 36. Relapses were more common in patients treated with pulse itraconazole (4/11) than in patients treated with continuous (2/12) or intermittent (2/13) terbinafine. Statistical analysis did not reveal any significant difference between relapse rates in the three groups.

Multiple nodular lesions of the chin and oral mucosa in a patient with Sjögren's syndrome

Sjögren's syndrome is an autoimmune disease characterised by generalised lymphoproliferation. Patients have an increased risk of developing lymphomas which are usually derived from mucosa-associated lymphoid tissue (MALT). We report a low grade, non-Hodgkin's lymphoma of the skin and oral mucosa in a patient with Sjögren's syndrome.

Are local and systemic conditions important for the development of onychomycosis?

Available epidemiological data indicate that the prevalence of onychomycosis due to dermatophytes increases with ageing. The aim of this study was to investigate the epidemiology of dermatophyte nail infections in 2 populations selected only on an age basis and to verify whether the presence of onychomycosis was associated with increased exposure to possible predisposing factors. From January to June 1995, the nails of 1,800 military recruits and 253 elderly individuals living in a nursing home were examined. Mycological studies were performed in all cases of suspected onychomycosis. The presence of systemic or local diseases that may favor fungal nail infection as well as exposure to environmental factors were assessed in the 2 populations. Onychomycosis was diagnosed in 8 recruits (0. 44%) and 38 of the elderly people (15%). The presence of onychomycosis was not related to the degree of exposure to environmental factors or to systemic or local diseases.

Onychomycosis due to Scopulariopsis brevicaulis: clinical features and response to systemic antifungals

Six cases of Scopulariopsis onychomycosis, including four patients with onychomycosis exclusively caused by Scopulariopsis brevicaulis and two patients with a mixed nail infection (S. brevicaulis + Tricophyton rubrum and S. brevicaulis + T. interdigitale), are reported. Four patients presented with a typical distal subungual onychomycosis characterized by subungual hyperkeratosis and onycholysis of the distal nail plate. In two patients, Scopulariopsis infection produced a total dystrophic onychomycosis associated with painful periungual inflammation. Three patients were treated with four pulses of itraconazole, 400 mg daily for 1 week a month, and three patients with terbinafine, 250 mg daily for 4 months. The mycological examination 8 months after discontinuation of treatment showed that one patient was mycologically cured whereas the remaining five patients still carried S. brevicaulis in their nails. The clinical examination at the end of the follow-up period showed a complete cure of the nail abnormalities in only one patient.

Treatment of dermatophyte nail infections: an open randomized study comparing intermittent terbinafine therapy with continuous terbinafine treatment and intermittent itraconazole therapy

BACKGROUND

terbinafine persists in the nail at effective concentrations for several weeks after discontinuation of treatment.

OBJECTIVE

Our purpose was to verify whether intermittent terbinafine therapy is effective in dermatophytic onychomycosis and to compare the results of intermittent terbinafine with those of intermittent itraconazole and continuous terbinafine treatment.

METHODS

An open, randomized study of 63 patients was performed with three treatment regimens: terbinafine, 250 mg daily (21 patients); terbinafine, 500 mg daily for 1 week every month (21 patients); or itraconazole, 400 mg daily for 1 week every month (21 patients). Treatment was continued for 4 months in toenail infections (60 patients) and 2 months in fingernail infections (3 patients).

RESULTS

At the end of the follow-up period (6 months after discontinuation of treatment) 16 of the 17 patients (94.1%) with toenail onychomycosis were mycologically cured in the terbinafine 250 mg group, 16 of 20 (80%) in the terbinafine 500 mg group, and 15 of 20 (75%) in the itraconazole group.

CONCLUSION

The percentage of patients who were mycologically cured was higher in the continuous terbinafine group than in the intermittent terbinafine and itraconazole groups, but statistical analysis did not reveal any significant difference between these cure rates.

Proximal subungual onychomycosis due to Microsporum canis

A case of proximal subungual onychomycosis due to Microsporum canis in a 36-year-old woman is presented. The onychomycosis involved the left thumb and the little fingernails, with thinning of the nail plate and crumbling of the nail plate surface. A milky-white discoloration of the proximal portion of the left thumbnail was also evident. A 2-mm longitudinal nail biopsy showed a large number of fungal elements in the whole length of the nail plate. Fungal hyphae were more numerous in the ventral nail plate and produced detachment of the superficial nail plate. The nail bed was not invaded by fungal elements and was devoid of inflammatory changes. Proximal subungual onychomycosis is uncommon in immunocompetent individuals but has frequently been described in patients with AIDS. In our patient, in whom the proximal subungual onychomycosis was due to M. canis, there were no clinical or biochemical signs of immunodeficiency. Oral treatment with terbinafine, 250 mg/daily for 2 months, produced clinical and mycological cure.