Itraconazole pulse therapy is effective in the treatment of Majocchi's granuloma: a clinical and pharmacokinetic evaluation and implications for possible effectiveness in tinea capitis.

Abstract

Majocchi's granuloma is a folliculitic and perifolliculitic dermatophyte infection of the dermis, a site that is not generally colonized by fungi in immunocompetent individuals. Topical agents are usually ineffective therapeutically because of the deep location of the infection. The objective of this study was to determine the effectiveness of oral itraconazole. We also examined the pharmacokinetics of the drug in scalp hair during pulse therapy. This information would then be useful in determining the efficacy of itraconazole administered by means of intermittent pulse dosing in the treatment of tinea capitis. Seven patients (age range 25-75 years) were treated up to three times with itraconazole pulse therapy, 200 mg twice daily for 1 week, with 2 weeks off between pulses. Samples of scalp hair and plasma were also obtained to determine the pharmacokinetics of the drug at these two sites. All seven patients responded to therapy, clinical and mycological cure being achieved after one pulse (one patient), two pulses (three patients), or three pulses (three patients, each with toenail onychomycosis); none relapsed over a 6-18-month follow-up period. In all six patients who received two or more pulses of itraconazole, almost complete cure was observed before the second pulse, with full resolution within 2 weeks of its completion. Itraconazole was also detected in the hair after 1 week, and at concentrations 2.6-fold and 3.4-fold higher, respectively, after the second and third pulses. After the discontinuation of therapy, itraconazole was then detectable in the hair for 9 months, at least in a female patient who did not have her hair cut. Two pulses of oral itraconazole therapy thus appear to be effective in the treatment of Majocchi's granuloma, and it is possible that one pulse may be sufficient in some patients. These data suggest that itraconazole pulse therapy should be effective in the treatment of tinea capitis.