Two cases of atypical periorificial dermatitis caused by Candida parapsilosis in patients volunteering in dog shelters

Candida is a genus of yeasts that can be a part of normal human skin flora, but may cause disease when the skin barrier is compromised. C. albicans is the most common pathogenic species of this genus, but in recent years infection with other species, such as C. parapsilosis has been growing. C. parapsilosis is a species of Candida that has been found in the skin of humans and other mammals, including dogs. In this brief report, the authors describe two cases of atypical periorifical infection with C. parapsilosis in patients who both volunteered in dog shelters. Owing to the atypical presentation of the fungal infections, the isolation of C. parapsilosis as the causative organism and their extensive history of exposure to dogs, these cases may represent the first evidence of possible zoonotic transmission of C. parapsilosis from dogs to humans.

Successful treatment of recalcitrant candidal intertrigo with Dr Michaels® (Fungatinex®) product family

Candidal intertrigo is an infection of the skin caused by Candida albicans that typically occurs in opposing cutaneous or muco-cutaneous surfaces. Because Candidiasis requires a damaged and moist environment for infection, it typically occurs in areas of friction such as the skin folds of the body. Candidal intertrigo is often difficult to treat and results are often unsatisfactory. In addition, there is a lack of evidence-based literature supporting prevention and treatments for candidal intertrigo. The aim of the study was to evaluate the efficacy of Dr Michaels® (also branded as Fungatinex®) products in the treatment of fungal intertrigo, in 20 women and 2 men with a mean age of 72. Five patients (3 female and 2 male) had type 2 diabetes and 16 (14 female and 2 male) were obese. The patients were treated with Dr Michaels® (Fungatinex®) moisturising bar, topical ointment (twice daily application) and oral herbal formulation, PSC 200 two tablets twice daily with food. After 2 weeks of treatment, the lesions had mostly resolved in all patients with only slight erythema evident. After six weeks of treatment using the moisturising bar, topical ointment and oral herbal formulations from the Dr Michaels® (Fungatinex®) product family, the lesions had totally resolved in 18 patients, while 4 patients had to continue the therapeutic protocol for another 2 weeks. Our results demonstrate that the Dr Michaels® (Fungatinex®) complementary product family is efficacious in the treatment of recalcitrant candidal intertrigo. Furthermore, this study highlights that the Dr Michaels® (Fungatinex®) product family is fast-acting and well tolerated with no serious adverse events reported. These data have important implications for resistant cases of candidal intertrigo where traditional therapies have failed.

Folliculocentric cutaneous presentation of disseminated Candida krusei infection in a patient with acute myeloid leukemia

Candida krusei (C. krusei) is a multidrug-resistant opportunistic fungal pathogen that may cause disseminated infections in immunocompromised hosts. However, its clinical and histologic features are not well-characterized. We present a unique case to contribute to the growing knowledge base associated with this organism. During hospitalization for neutropenic fever, a 19-year-old man with acute myeloid leukemia, who underwent hematopoietic stem cell transplantation, developed a generalized folliculocentric eruption following initiation of antifungal therapy for newly diagnosed C. krusei fungemia. Despite adequate antifungal coverage and negative blood cultures, the follicular-based erythematous papules persisted. Biopsies demonstrated yeast within ruptured follicles, without angiotropism or involvement of the interfollicular dermis, subcutaneous tissue, or stratum corneum. Concurrent skin tissue cultures confirmed C. krusei. The patient remained febrile despite aggressive antifungal therapy, with relapse of leukemia and subsequent death. Our case is unusual given the development of cutaneous lesions following clearance of fungemia, with yeast limited to ruptured follicular lumina, possibly indicating a primary cutaneous source or early transfollicular/transepidermal elimination. Given the limited available descriptions of cutaneous histopathology for C. krusei, we seek to add to the understanding of its pathophysiology and aid in the diagnosis and treatment of this often fatal infection.

Infections with Candidatus Neoehrlichia mikurensis and Cytokine Responses in 2 Persons Bitten by Ticks, Sweden

The prevalence of Candidatus Neoehrlichia mikurensis infection was determined in 102 persons bitten by ticks in Sweden. Two infected women had erythematous rashes; 1 was co-infected with a Borrelia sp., and the other showed seroconversion for Anaplasma phagocytophilum. Both patients had increased levels of Neoehrlichia DNA and serum cytokines for several months.

Signaling through IL-17C/IL-17RE is dispensable for immunity to systemic, oral and cutaneous candidiasis

Candida albicans is a commensal fungal microbe of the human orogastrointestinal tract and skin. C. albicans causes multiple forms of disease in immunocompromised patients, including oral, vaginal, dermal and disseminated candidiasis. The cytokine IL-17 (IL-17A) and its receptor subunits, IL-17RA and IL-17RC, are required for protection to most forms of candidiasis. The importance of the IL-17R pathway has been observed not only in knockout mouse models, but also in humans with rare genetic mutations that impact generation of Th17 cells or the IL-17 signaling pathway, including Hyper-IgE Syndrome (STAT3 or TYK2 mutations) or IL17RA or ACT1 gene deficiency. The IL-17 family of cytokines is a distinct subclass of cytokines with unique structural and signaling properties. IL-17A is the best-characterized member of the IL-17 family to date, but far less is known about other IL-17-related cytokines. In this study, we sought to determine the role of a related IL-17 cytokine, IL-17C, in protection against oral, dermal and disseminated forms of C. albicans infection. IL-17C signals through a heterodimeric receptor composed of the IL-17RA and IL-17RE subunits. We observed that IL-17C mRNA was induced following oral C. albicans infection. However, mice lacking IL-17C or IL-17RE cleared C. albicans infections in the oral mucosa, skin and bloodstream at rates similar to WT littermate controls. Moreover, these mice demonstrated similar gene transcription profiles and recovery kinetics as WT animals. These findings indicate that IL-17C and IL-17RE are dispensable for immunity to the forms of candidiasis evaluated, and illustrate a surprisingly limited specificity of the IL-17 family of cytokines with respect to systemic, oral and cutaneous Candida infections.

Primary cutaneous Candida tropicalis infection in a patient with B-cell lymphoma

We report the case of a 61-year-old man with diffuse large B-cell lymphoma who presented with a tender skin lesion on the left side of the flank of 5 weeks' duration after undergoing myeloablative chemotherapy. Prior treatment with intravenous vancomycin showed minimal response. Clinical examination revealed a tender, indurated, erythematous plaque on the left side of the flank. A skin biopsy demonstrated a lymphohistiocytic and neutrophilic infiltrate with deep dermal necrosis and fungal forms in the dermis and subcutis. A tissue culture grew Candida tropicalis; however, blood cultures remained negative for yeast. A diagnosis of primary cutaneous candidiasis was made based on the lack of response to antibiotics, tissue evidence of C tropicalis, and negative blood cultures. Although rare, primary cutaneous candidiasis should be considered in immunocompromised patients presenting with cellulitis or an abscess that is unresponsive to treatment.

Histopathology of the nail unit

In this report, we review several inflammatory infectious and tumoral conditions of the nail unit. We emphasize the anatomic peculiarities of such pathologies of the nail unit and provide some required diagnostic criteria.

IL-23 and IL-17A, but not IL-12 and IL-22, are required for optimal skin host defense against Candida albicans

IL-23 and Th17 cells play important roles in host defense against systemic infections with extracellular bacteria and fungi, although their roles in immunity against localized skin infections are less well defined. Here, the contributions of IL-23 and Th17 cytokines in host defense against cutaneous Candida albicans infection were evaluated. Mice deficient in IL-23 or IL-17A demonstrated delayed healing and decreased IL-17A production after skin infection with C. albicans compared with wild-type mice or mice deficient in IL-12 or IL-22. Histologic examination revealed epidermal hyperplasia overlying infected dermis four days postinoculation in wild-type mice. In IL-23-deficient mice, fungal burden was greater in skin, neither IL-17A nor IL-22 mRNAs were expressed postinfection, and these mice demonstrated only minimal epidermal hyperplasia. Exogenous recombinant IL-17A injected at the site of skin infection promoted more rapid healing of candidiasis in both wild-type mice and mice deficient in IL-23 and IL-12. Taken together, these results demonstrate that IL-23 and IL-17A, but not IL-12 and IL-22, are required for optimal host defense against cutaneous candidiasis. In addition, recombinant IL-17A may serve as a potential therapy to enhance healing in individuals with chronic cutaneous candidiasis.

Ulcerated plaque under a ruby ring in an immunosuppressed patient

We report a primary inoculation fungal infection in a 76-year-old man with acute myeloid leukemia. The patient presented with a painful red plaque located where he routinely wore a ruby ring. Histopathology revealed multiple branching septate hyphae. Cultures confirmed Fusarium and Candida parapsilosis infection. A short discussion of these organisms follows.

The yeast connection: is Candida linked to breastfeeding associated pain?

OBJECTIVE

The objective of the study was to determine whether the isolation of Candida from breastfeeding women is associated with self-reported pain.

STUDY DESIGN

A prospective cohort study was conducted from May 2004 to July 2006. Ninety-eight breastfeeding women were enrolled: 20 women reported breastfeeding associated pain, and 78 women were asymptomatic. Cultures were obtained from breast milk, areolae, and infants' oropharynx.

RESULTS

Six of the 20 symptomatic women had breast milk cultures positive for yeast, compared with 6 of 78 controls (30% vs 7.7%, P = .015). Among the 12 women from whom yeast was isolated, 11 grew Candida albicans. Incidence of Staphylococcus aureus isolation did not differ significantly between groups (5 of 20 vs 15 of 78, P > .05).

CONCLUSION

C. albicans is found more often in breastfeeding mothers who report pain as compared with asymptomatic breastfeeding mothers. Further studies, including treatment trials, are needed to determine whether Candida plays an etiologic role in breastfeeding associated pain.

[A case of disseminated candidiasis as an initial presentation of AIDS]

A 44-year-old woman referred for skin eruptions and an altered mental status was confirmed to have HIV infection on Western Blot analysis. Her CD4+ T cell count was 15/microl. On admission, she appeared quite ill with respiratory distress. Chest X-ray showed bilateral patchy infiltration and pleural effusions. She was treated with cefotaxime, pentamidine, and antituberculosis drugs, but her condition worsened and dopamine was initiated. Intensive treatment failed, and she died the following day. An autopsy showed purplish papules on her face and trunk and multiple white nodules in her liver, spleen and lungs. Culture was positive for Candida Albicans, yielding a diagnosis and of disseminated candidiasis. It is rare for HIV patients to be diagnosed with disseminated candidiasis, since the pathogenesis usually requires disruption of the mucosal barrier. The defense mechanism against disseminated candidiasis is mainly neutrophils and macrophages, and its dysfunction is not a primary characteristic of HIV infection. To the best of our knowledge, this is the first report in Japan of a HIV patient to have disseminated candidiasis.

Narrow-spectrum staining pattern of Pityrosporum

BACKGROUND

Broad-spectrum fungal stains are used to detect fungal organisms, but narrow-spectrum stains can assist in fungal differential diagnosis. These stains include mucicarmine and Fontana-Masson (FM) for Cryptococcus, Alcian Blue for Cryptococcus and Blastomyces, Congo Red for Blastomyces and Coccidioides, and Ziehl-Neelsen for some examples of Blastomyces and Histoplasma. Pityrosporum is increasingly being recognized as a pathogen capable of significant cutaneous and systemic infections, but the narrow-spectrum staining pattern of Pityrosporum has not yet been systematically studied and reported.

METHODS

Paraffin-embedded archival tissue from 10 skin biopsies containing Pityrosporum was stained with Alcian Blue, Congo Red, Ziehl-Neelsen acid-fast stain, and FM stain. In addition to the 60-min staining time, a modified FM stain with 15-, 30-, and 45-min staining times was also performed.

RESULTS

All cases stained positive with Alcian Blue, Congo Red, and FM stains and negative with the Ziehl-Neelsen stain. The modified FM stain with the 15-min staining time showed significant staining in more than 50% of the cases.

DISCUSSION

The narrow-spectrum staining pattern of Pityrosporum distinguishes it from Cryptococcus, Blastomyces, Candida, Histoplasma, and Coccidioides.

Topical therapy for dermatophytoses: should corticosteroids be included?

Dermatophytoses, commonly known as ringworm or tinea, represent superficial fungal infections caused by dermatophytes, which are among the most common infections encountered in medicine. The use of corticosteroid-containing combinations in dermatophyte infections that are usually treated with topical medications is still a much-debated issue. The addition of a corticosteroid to local antifungal therapy may be of value in reducing local inflammatory reaction and thus carries the theoretical advantage of rapid symptom relief in acute dermatophyte infections associated with heavy inflammation. However, the use of such combinations requires caution as they have some potential risks, especially with long-term use under occlusive conditions. Corticosteroid-induced cutaneous adverse effects have been reported primarily in pediatric patients due to inappropriate application of these preparations on diaper areas. Additionally, the corticosteroid component may interfere with the therapeutic actions of the antifungal agent, or fungal growth may accelerate because of decreased local immunologic host reaction, such that underlying infection may persist, and dermatophytes may even acquire the ability to invade deeper tissues. Analysis of the literature documenting clinical study data and adverse reactions related to combination therapy, drew the following conclusions: (i) combination products containing a low potency nonfluorinated corticosteroid may initially be used for symptomatic inflamed lesions of tinea pedis, tinea corporis, and tinea cruris, in otherwise healthy adults with good compliance; (ii) therapy should be substituted by a pure antifungal agent once symptoms are relieved, and should never exceed 2 weeks for tinea cruris and 4 weeks for tinea pedis/corporis; and (iii) contraindications for the use of these combinations include application on diaper or other occluded areas and facial lesions, as well as in children <12 years of age and in immunosuppressed patients for any reason.

'Decubital candidosis': a study of 26 cases

BACKGROUND

Candidoses are infections caused by yeasts of the genus Candida. 'Decubital candidosis' is a particular form of cutaneous candidosis that occurs on the dorsal skin of chronically bedridden patients; there are very few studies about this presentation in the medical literature.

OBJECTIVE

To study the clinical, mycological and histopathological features of 26 cases of 'decubital candidosis' along with factors that may predispose to it.

METHODS

Twenty-six patients were included and their general characteristics and clinical lesions were carefully studied. The presence of candidosis in other organs and the occurrence of predisposing factors were searched by reviewing the medical records. Mycological studies were performed and cutaneous biopsies were taken.

RESULTS

Median age of patients was 46 years, 11 were male and 15 were female, 25 were caucasian, one was Asian and no one was Afro-Carribean. This finding suggests a greater resistance of Afro-Carribean skin to this form of candidosis. The median time of hospitalization until rash occurrence was 24.8 days. Clinical lesions consisted of erythema, erosions, pustules, papules and desquamation. The most significant predisposing factors for this eruption were prolonged bedrest and broad-spectrum antibiotics. Candidosis on other body sites was diagnosed in 10 cases and additional specific predisposing factors were observed in all 10. Potassium hydroxide examination was a reliable test for diagnosing this disease. Candida albicans was the agent in all 26 cases. Spongiform pustules were the most significant histopathological findings and yeasts were restricted to the horny layer in all biopsied cases.

CONCLUSION

'Decubital candidosis' is probably induced by prolonged bedrest and facilitated by long-term use of antibiotics. This cutaneous infection does not seem to predispose to systemic candidosis.

A multicenter, open-label study to assess the safety and efficacy of ciclopirox topical suspension 0.77% in the treatment of diaper dermatitis due to Candida albicans

Ciclopirox is a broad-spectrum antifungal, antibacterial, and anti-inflammatory agent. This open-label study investigated the safety and efficacy of ciclopirox topical suspension 0.77% in the treatment of diaper dermatitis due to Candida albicans (C. albicans). Forty-four male and female subjects aged 6 to 29 months were included in the study. Study medication was applied topically to the affected diaper area twice daily for 1 week. Subjects were clinically evaluated at baseline and days 3, 7, and 14 (7 days post-treatment). Safety and efficacy variables included adverse events, mycological culture studies, KOH tests, Severity Scores, and Global Evaluation of Clinical Response. All adverse events were mild to moderate and considered not related to the study medication. Treatment provided statistically significant improvement (P < .05) for both the rate of mycological cure and reduction of Severity Score at each time point compared with baseline. Ciclopirox was safe and effective in the treatment of diaper dermatitis due to C. albicans.

Diabetes mellitus and candidiases

Patients in various clinical states of diabetes mellitus (according to the recommendation of the American Diabetes Association) as a primary diagnosis were examined for fungal infections by Candida species. Candida spp. were detected in urine, in the material taken from the mouth cavity, nails, skin lesions, ears and eyes, by cultivation on the Sabouraud agar, CHROMagar Candida, and by saccharide assimilation. In the group of diabetics with symptoms of oral candidiasis and denture stomatitis C. albicans was identified in 8 cases, C. tropicalis in 3, C. parapsilosis in 2; 1 strain of C. guilliermondii was also isolated. In patients with urinary tract infections the presence of C. albicans was shown in 12 cases; C. parapsilosis was detected in 6 cases and two strains of each C. tropicalis and C. krusei were also isolated. In patients with leg ulcers C. albicans (25 cases), C. parapsilosis (5), C. tropicalis (3) and one strain of each C. krusei and C. robusta were isolated. Otomycosis was associated with one strain of C. albicans, C. parapsilosis, C. tropicalis and C. guilliermondii. C. albicans was most frequently associated with onychomycosis, paronychia and endophthalmitis; C. parapsilosis was the second most rated yeast.

Diagnostic value of signs and symptoms of mammary candidosis among lactating women

Mammary candidosis in lactating women is not well defined and is most often presumptively diagnosed by signs and symptoms. This study evaluates the sensitivity, specificity, positive predictive value, and likelihood ratios of signs and symptoms of mammary candidosis based on the presence of Candida species on the nipple/areola or in the milk. In this prospective cohort study, the nipple/areola skin and milk of 100 healthy breastfeeding mothers were cultured from each breast at 2 weeks postpartum, and mothers were interviewed regarding signs and symptoms associated with mammary candidosis between 2 and 9 weeks postpartum. Positive predictive value for Candida colonization was highest when there were 3 or more signs or symptoms simultaneously or when flaky or shiny skin of the nipple/areola was reported together or in combination with breast pain.

Generalized fungal infection in a patient with AIDS appearing as skin papules

Human immunodeficiency virus infection (HIV) is unique among cutaneous fungal infections caused by defects of the cell-mediated immune system. Infections with Candida albicans occur with increased frequency and severity among HIV-infected individuals. Oral candidiasis is the most common manifestation, superficial cutaneous infections of the dermis are rarely seen. We report a HIV-positive man from Cameroon presenting with generalized cutaneous papules and nodes, oral candidiasis, and soor esophagitis, who was successfully treated with fluconazole monotherapy.

Candida--agent of the diaper dermatitis?

Occurrence of Candida spp. was determined in a population of 60 infants, 1-15-month-old, with diaper dermatitis, admitted to a neonatal intensive care unit in Hospital Saca (Kosice, Slovakia). Specimens were obtained from the perianal, pubic, inguinal, or gluteal areas that showed signs of secondary infection as manifested by erythema, oozing, vesiculopustular lesions, and pus formation. The most frequently isolated species was C. albicans (41), followed by C. parapsilosis (8), C. tropicalis (4), C. pulcherrima (4), C. guilliermondii (2), and C. zeylanoides (1). Other organisms present in the mixed culture from the diaper area were Staphylococcus aureus (6), Escherichia coli (3), and 2 strains of each group B and D streptococci, and Proteus mirabilis. Infants diapered exclusively in disposable diapers showed less rash than those diapered exclusively or sometimes in cloth diapers.

Nail dystrophy in congenital cutaneous candidiasis

Congenital cutaneous candidiasis (CCC) is usually a benign condition characterized by various skin manifestations and is rarely associated with nail changes. We report a premature infant with CCC who developed dystrophy of all 20 nails at about 1 month of age. Nail dystrophy due to Candida albicans in the young infant may be differentiated from other congenital or hereditary nail malformations by appearance, recovery of the organism in nail culture, and complete resolution over a period of several months.

[Diagnostic image (143). A neonate with a skin disorder. Congenital cutaneous candidiasis]

A premature neonate was born with a generalized eruption of vesicles, within a day developing into an erythrodermia, with bullae and widespread desquamation, due to congenital cutaneous candidiasis.

The pustular disorders

The pustular disorders constitute a subgroup of the vesiculobullous disorders defined by the presence of eosinophils or neutrophils with prominent accompanying intercellular edema or a canthelysis involving various levels of the epithelium. Herein, we describe the clinical and pathologic attributes of the subcorneal, infectious, neonatal, papulosquamous, drug-induced and miscellaneous pustular conditions.

Cytokine expression induced by Candida albicans in a model of cutaneous candidosis based on reconstituted human epidermis

Skin equivalents based on reconstituted human epidermis have been used recently to establish models for allergic/irritant contact dermatitis and cutaneous candidosis. In the present study the cytokine expression pattern and the morphological alterations in experimental cutaneous candidosis were investigated by RT-PCR and histological analysis. In experimental cutaneous C albicans infection the mRNA expression levels of interleukin (IL)-1a, IL-1beta, IL-8, GM-CSF, Exodus-2, tumour necrosis factor-alpha and PSL (P-selectin ligand) were upregulated. Cytokine profile and histological features of infected skin (separation of keratinocytes, oedema, vacuolisation) were comparable to that seen in experimental contact dermatitis. These immunomodulatory and morphological similarities might reflect a common pathogenesis factor in both diseases.

Recombinant human antibody single chain variable fragments reactive with Candida albicans surface antigens

A combinatorial phage display library expressing human immunoglobulin heavy and light chain variable regions was used to identify phage clones capable of binding to the surface of Candida albicans blastoconidia. Single chain antibody variable fragments (scFv) derived from three clones detected C. albicans antigens by indirect immunofluorescence assay (IFA), enzyme-linked immunosorbent assay (ELISA), and Western blotting. The antigens detected were conserved among different strains of C. albicans and several other Candida species. Two scFv clones detected antigens specifically expressed by C. albicans blastoconidia; the third detected antigens in both blastoconidia and filamentous forms of C. albicans. The antigens containing the epitopes recognized by all three scFv could be extracted from blastoconidia by dithiothreitol, suggesting attachment to the cell wall via sulfhydryl bonds. Epitope detection by the scFv was sensitive to treatment of C. albicans blastoconidia with sodium periodate, but not proteinase K, indicating the cognate epitopes were composed of carbohydrate. Antigenic determinants for each of the three scFv were detected by immunohistochemical staining of skin sections from a model of cutaneous candidiasis, demonstrating expression in vivo. Through selection for the ability to bind intact organisms, the phage display system provides a means to rapidly identify monoclonal binding ligands to Candida surface antigens. Being entirely human, mature antibodies generated from the scFv have potential utility in the treatment of candidiasis.

Superficial fungal infection of the skin. Where and how it appears help determine therapy

Superficial fungal infections of the skin are a common presentation in clinical practice. Any skin surface, the mucous membranes, nail plates, and nail beds can be affected. Tinea pedis is the most common fungal infection and may affect up to 70% of the adult population worldwide. Ubiquitous candidal organisms are found in the oral flora of many healthy persons and result in infection in the presence of certain host factors or immunodeficiency disorders. Onychomycosis has had an increasing incidence worldwide, and it now accounts for almost half of all nail disorders. These and many other infections can have varying presentations as well as features that resemble nonfungal disorders. Therefore, it is important that primary care physicians are familiar with the many cutaneous fungal infections and their differential diagnosis to ensure that appropriate therapy is selected.

Atrichia, ichthyosis, follicular hyperkeratosis, chronic candidiasis, keratitis, seizures, mental retardation and inguinal hernia: a severe manifestation of IFAP syndrome?

A boy with congenital atrichia, ichthyosis follicular, keratitis, cutaneous infections and a huge inguinal hernia, but without deafness is reported. We believe it represents a new case of a rare X-linked recessive syndrome known as ichthyosis follicularis, alopecia, photophobia syndrome (IFAP). The differential diagnosis from keratitis ichthyosis deafness is discussed. The cutaneous infections seen in our case suggest the possibility of considering a genetic link between these syndromes.

Light and electron microscopic findings in a model of human cutaneous candidosis based on reconstructed human epidermis following the topical application of different econazole formulations

The effects of two commercially available econazole formulations (econazole nitrate cream, econazole liposome gel) on uninfected reconstructed human epidermis and on a model of human cutaneous candidosis were investigated. The morphological alterations of the reconstructed epidermis after infection and treatment were analysed with light and electron microscopy. The most important Candida albicans-specific alterations of the recently established in vitro model of human cutaneous candidosis were scaling, hyperkeratosis, parakeratosis, dyskeratosis and spongiosis. A single application of the cream to the uninfected reconstructed epidermis caused more epidermal barrier damage and irritative toxic effects than the liposome gel. Treatment of the modelled human cutaneous candidosis with the cream also resulted in increased toxic effects, e.g., enhancement of scaling with invasion of Candida albicans blastospores into the stratum corneum and intracellular vacuoles. After application of the liposomal preparation invasion of Candida albicans in the stratum corneum could not be detected and toxic effects were reduced. Some of the Candida albicans-specific alterations such as hyperkeratosis, focal thickening of the stratum corneum, dyskeratosis and parakeratosis were completely eliminated. The liposomal formulation increased slightly the morphological alterations of the blastospores. Remnants of the cream formulation could be detected only very rarely in the stratum corneum or the blastospores. The liposomal preparation showed a strong affinity for the Candida albicans cells and the stratum corneum. Intact liposomes could even be observed in the intercellular spaces of the upper stratum corneum. As successful treatment depends on the ability to target the liposomal agent to the wanted site of action, this might be useful for more effective treatment of cutaneous candidosis.

[Pustular candidiasis in heroin addicts]

INTRODUCTION

Pustular candidiasis in heroin addicts is a rare entity in dermatology. We report a case.

CASE REPORT

A 29-year-old female heroin addict developed a painful pustular growth on the scalp. There was no fever. Multiple follicular pustulae measuring 2 to 3 mm were associated with hyperesthesia of the scalp and painful cervical nodes. Biopsy showed acute ostiofolliculitis with a few blastospores and mycelial filaments. Candida albicans was isolated from the pustulae and the buccal cavity. Candida serology was positive (indirect immunofluorescence 1/100, coelectrosyneresis: 4 archs). Search for other localizations and HIV serology were negative. The last injection of brown heroin had been taken 15 days earlier; lemon had been added. Treatment with flucanazole (400 mg/d) led to improvement within 48 hours.

DISCUSSION

Sudden development of pustulae or nodules in pilous zones in a heroin addict should suggest the diagnosis. Outcome depends on early treatment after diagnosis and search for other localizations. Our case presented two particular aspects: ostiofollicular localization of the pustulae and a long delay (15 days) between the (presumably) last injection and the development of the lesion. Folliculitis develops almost exclusively in addicts who use brown heroin. Contamination by Candida albicans results from the lemon used to improve solubility at injection.

A model of human cutaneous candidosis based on reconstructed human epidermis for the light and electron microscopic study of pathogenesis and treatment

The use of reconstructed human epidermis provided the basis for an in vitro model of human cutaneous candidosis. Candida albicans blastospores on the surface of reconstructed human epidermis provoked the following changes within 72 h: superficial keratin degradation, scaling, hyperkeratosis, parakeratosis, dyskeratosis representing hyperproliferative stress, spongiosis, and vesiculation. Great differences in the intensity of these reactions of intact reconstructed human epidermis or chemically or mechanically damaged reconstructed human epidermis illustrate the importance of the stratum corneum as a barrier. Uninfected reconstructed human epidermis showed prominent cell proliferation representing wound healing 72 h after mechanical or chemical pretreatment. These signs of repair were blocked in the presence of C. albicans and the blastospores were able to invade the stratum corneum. When desmosomes were accessible, a high affinity of C. albicans blastospores to these structures was observed. A single application of an econazole liposome dispersion decreased scaling, hyperkeratosis and dyskeratosis. Morphological alterations of C. albicans blastospores after treatment with the econazole liposome dispersion in the proposed ill vitro model were identical, as described in established animal models. This reconstructed human epidermis model of cutaneous disease may provide insight into the pathogenesis and treatment of cutaneous candidosis and may provide a substitute for animal models and investigations on humans.

Extensive skin candidosis in an adult: effective treatment with itraconazole

A 34-year-old man with 6 years' untreated erythematous scaling of the skin was diagnosed as having extensive skin candidosis. Oral itraconazole was administered for 4 weeks (400 mg day-1 for the first 3 weeks and 200 mg day-1 for the last week). At the end of the 4-week treatment period, the rash was completely cleared from all skin sites, and Candida albicans was absent in culture tests on tissue samples. No adverse events were reported by the patient, and laboratory analysis revealed no abnormalities in the liver, kidney and haematological systems. Oral itraconazole is therefore an effective treatment for extensive skin candidosis.

[An evaluation of the efficacy of Pimafucin in candidiasis of the skin and mucous membranes]

Results were studied of use of different dosage forms of pimafucin in candidiases in children. It was found out that the above medicinal agent is an effective anticandidiasis drug that can easily be tolerated by children. A beneficial clinical effect was noted in treatment of candidiasis complications in those children suffering from atopic dermatitis. The above drug can, we believe, come into widespread use in pediatric dermatovenereology.

Cutaneous congenital candidiasis: a case report

Candida albicans is a frequent pathogen of the female genital tract, especially during pregnancy. Congenital candidiasis can occur as cutaneous or disseminated infection. We report a case of congenital cutaneous candidiasis, which may occur more frequently than is indicated by the literature. This is followed by a discussion of the pathogenesis, clinical presentation, diagnosis, and treatment of this infection.

Congenital cutaneous candidiasis: case report and review

This report describes a preterm infant with congenital cutaneous candidiasis associated with paronychia, dystrophy of the nail plates, and marked, transient leukocytosis.

Oral fluconazole treatment of fungating candidiasis in the keratitis, ichthyosis and deafness (KID) syndrome

We report a patient with a congenital ichthyosiform eruption, sensorineural deafness, vascularizing keratitis and pannus formation, and hypotrichosis, who developed recalcitrant fungating candidal plaques on the skin. There was no family history of similar disease, or of consanguinity. The steroid sulphatase level in the keratin was within normal limits, and this finding excluded a diagnosis of X-linked recessive ichthyosis. Treatment with oral fluconazole for 14 weeks resulted in complete resolution of the fungating lesions, and there has been no evidence of recurrence during a 12-month follow-up period.

Pathogenesis of Candida infections

Candida infections of the skin and superficial mucosal sites are the result of an interplay between fungal virulence and host defenses. Epidermal proliferation and T-lymphocyte immune responses are expressed by the host to combat fungal invasion, but inflammatory responses and nonspecific inhibitors also probably play a role. Candida albicans can express at least three types of surface adhesion molecules to colonize epithelial surfaces, plus an aspartyl proteinase enzyme able to facilitate initial penetration of keratinized cells. Deeper penetration of keratinized epithelia is assisted by hypha formation, and C. albicans hyphae may use contact sensing (thigmotropism) as a guiding mechanism. Pathogenesis requires differential expression of virulence factors at each new stage of the process: a propensity for rapid alteration of the expressed phenotype in C. albicans may therefore be a significant factor in establishing the comparatively high pathogenic potential of this species.

A novel model of cutaneous candidiasis produced in prednisolone-treated guinea-pigs

In an attempt to develop an animal model of cutaneous candidiasis useful for the pre-clinical evaluation of antifungal drugs, experimental cutaneous Candida albicans infections were produced in mature and immature guinea-pigs treated with prednisolone. The morbidity of this model in terms of the extent and the duration of the superficial infection was compared with that of two other reported models: those produced by alloxan treatment, or the use of occlusive dressings. Infected animals were also included which received neither of these treatments. The Candida infection continued steadily for 14 days or more in both mature and immature animal groups treated subcutaneously with prednisolone and appeared to be more suitable than that produced with alloxan treatment or under occlusive dressings. In prednisolone-induced infection, most of the micro-organisms were confined to the epidermis and there was no evidence of their dermal penetration during the 14 day experimental period. In view of these facts, we attempted a more quantitative method by counting viable Candida in order to evaluate antimycotics in a shorter therapy period during which animals would receive less exposure to the vehicle. These findings appear to indicate that the experimental model of cutaneous C. albicans infection produced in prednisolone-treated mature and immature guinea-pigs would be useful for studies on the therapeutic efficacy of antifungal agents against cutaneous candidiasis.

Liposomal amphotericin-B (AmBisome) for treatment of cutaneous widespread candidosis in an infant with methylmalonic acidaemia

In a 10-week-old infant with vitamin B12-unresponsive methylmalonic acidaemia, cutaneous candidosis (Candida albicans) progressed rapidly despite topical antifungal treatment. After 1 week of intravenous therapy with liposomal amphotericin-B (AmBisome) the dermatitis disappeared completely and blood cultures were sterile. No side-effects were observed. This is one of the first experiences in the treatment of infants with this new antifungal agent.

Ringworm-like cutaneous candidiasis: report of a case of localized type

A 52-year-old Japanese female patient with ringworm-like cutaneous candidiasis on the right axillary area is described. It appeared to have developed in relationship to previous local steroid therapy in this area for a long time.

Gangrene of the anterior abdominal wall after orthotopic liver transplantation: invasive cutaneous candidiasis

Fungal infections following liver transplantation are not uncommon and may be life-threatening. Superficial candidal infections of the bronchus, oesophagus and urinary tract are the most common mode of presentation. Invasive cutaneous and subcutaneous candidiasis is, however, very rare. We report two patients with invasive cutaneous and subcutaneous candidiasis after orthotopic liver transplantation.

Two cases of onychomycosis due to Candida zeylanoides

As the range of yeasts and filamentous fungi reported to cause onychomycosis has increased, uncommon genera or species have appeared in the literature. Candida zeylanoides is an example of a yeast rarely involved in human pathology. Between 1989 and 1991, two cases of onychomycosis due to this yeast were encountered in Wollongong, NSW. There were similarities in the cases, as both involved finger- or thumb-nails and both patients were female (one sixty years of age and the other, seventy-two). Evidence of pathogenicity is presented and subsequent topical treatment was successful in both cases.