Topical Antifungal Treatment Research Articles

Dermatomycoses: topical and systemic antifungal treatment

Topical antifungals with activity against dermatophytes include amorolfine, allylamines, azoles, ciclopiroxolamine, and tolnaftate. Polyene antimycotics, such as amphotericinB and nystatin, alternatively, miconazole are suitable for yeast infections of the skin and mucous membranes. For severe yeast infections of the skin and mucous membranes, oral triazole antimycotics, such as fluconazole and itraconazole, are used. Pityriasis versicolor is treated topically with antimycotics, and in severe forms also orally with itraconazole, alternatively fluconazole. Terbinafine, itraconazole and fluconazole are currently available for the systemic treatment of severe dermatophytoses, tinea capitis and onychomycosis. In addition to proven therapeutic regimens, unapproved (off-label use) intermittent low-dose therapies are increasingly being used, particularly in onychomycosis. Oral antimycotics for the treatment of tinea capitis and onychomycosis in children and adolescents can only be used off-label in Germany. In general, any oral antifungal treatment should always be combined with topical antifungal therapy. In tinea corporis and tinea cruris caused by Trichophyton (T.) mentagrophytes ITS (internal transcribed spacer) genotype VIII (T.indotineae), there is usually terbinafine resistance. Identification of the species and genotype of the dermatophyte and resistance testing are required. The drug of choice for T.mentagrophytes ITS genotype VIII dermatophytoses is itraconazole. In individual cases, treatment-refractory onychomycosis may be due to terbinafine resistance of T.rubrum. Here too, resistance testing and alternative treatment with itraconazole should be considered. Therapy monitoring should be carried out culturally and, if possible, using molecular methods (polymerase chain reaction). Alternative treatment options include laser application, and photodynamic therapy (PDT).

Phase-Dependent Differential In Vitro and Ex Vivo Susceptibility of Aspergillus flavus and Fusarium keratoplasticum to Azole Antifungals.

Fungal keratitis (FK) is an invasive infection of the cornea primarily associated with Aspergillus and Fusarium species. FK is treated empirically with a limited selection of topical antifungals with varying levels of success. Though clinical infections are typically characterized by a dense network of mature mycelium, traditional models used to test antifungal susceptibility of FK isolates exclusively evaluate susceptibility in fungal cultures derived from asexual spores known as conidia. The purpose of this study was to characterize differences in fungal response when topical antifungal treatment is initiated at progressive phases of fungal development. We compared the efficacy of voriconazole and luliconazole against in vitro cultures of A. flavus and F. keratoplasticum at 0, 24, and 48 h of fungal development. A porcine cadaver corneal model was used to compare antifungal efficacy of voriconazole and luliconazole in ex vivo tissue cultures of A. flavus and F. keratoplasticum at 0, 24, and 48 h of fungal development. Our results demonstrate phase-dependent susceptibility of both A. flavus and F. keratoplasticum to both azoles in vitro as well as ex vivo. We conclude that traditional antifungal susceptibility testing with conidial suspensions does not correlate with fungal susceptibility in cultures of a more advanced developmental phase. A revised method of antifungal susceptibility testing that evaluates hyphal susceptibility may better predict fungal response in the clinical setting where treatment is often delayed until days after the initial insult.

Editorial: Navigating the Frontiers in Pharmaceutical Sciences: A Digest of Review and Original Articles

Abstract: As an editor of this esteemed journal, it is my pleasure to introduce the brilliant research encapsulated in the new issue, featuring a compilation of intriguing review and original articles that cover a broad spectrum of pharmaceutical sciences. The review articles commence with an enlightening piece on the utilization of PLGA, an innovative biodegradable polymer, in drug delivery systems, authored by Sonawane, Pingale, and Amrutkar. They delve into the groundbreaking capabilities of this polymer and how it is revolutionizing the realm of drug delivery. This is followed by Koliyote and Shaji’s fascinating review on the synthesis, characterization, and applications of gold nanoparticles using plant extracts, which highlights the natural, sustainable, and cost-effective approach towards nanotechnology in therapeutics. Govindaswamy, Dhivya, and Sivaprakasam present a timely systematic review on the prevalence and complications of Diabetes Mellitus in India, drawing attention to the need for effective management strategies. This is succeeded by Swain’s comprehensive exploration of the antidiabetic properties of natural products from Cyperus species plants, which suggests promising therapeutic potential. The original articles offer a deeper insight into various dimensions of pharmaceutics, pharmacognosy, pharmaceutical chemistry, and pharmacy practice. Notable among these are studies by Sharma and Verma on double-layered transdermal patches of Diclofenac Diethylamine, and Bhambar and Gadakh’s research on the formulation of a sustained release mucoadhesive microcapsule of Baclofen, demonstrating the evolution of drug delivery systems. Kathpalia, Venkatesh, and Sathe introduce a novel topical film-forming clotrimazole emulgel, which could revolutionize topical antifungal treatment. Read more...

Outcome of fosravuconazole treatment for onychomycosis refractory to topical antifungal agents.

Fosravuconazole L-lysine ethanolate (F-RVCZ) is an oral antifungal agent approved in Japan for the treatment of onychomycosis. We treated 36 patients (mean age 77.6 years) with onychomycosis that had been refractory to long-term topical treatment. The patients took F-RVCZ (100 mg ravuconazole) once daily for a mean of 11.3 weeks, and were followed up for an average of 48 weeks (mean 48.3 ± 2.1 weeks). The mean rate of improvement of the affected nail area at 48 weeks was 59.4%, and 12 patients achieved complete cure. Patients with total dystrophic onychomycosis (TDO) showed a significantly lower improvement rate than those with distal and lateral subungual onychomycosis (DLSO), and those with an affected nail area of 76%-100% at the first visit showed a significantly lower improvement rate than those with an affected nail area of 0%-75%. Six patients had adverse events necessitating treatment discontinuation, but the symptoms and laboratory data improved without specific treatment in all of them. The data suggest that F-RVCZ would be effective in various age groups, including the elderly, and even in patients with onychomycosis refractory to long-term topical antifungal treatment. It was also suggested that its early use in mild cases might achieve a higher rate of complete cure. Furthermore, the average cost of oral F-RVCZ therapy was lower than that for topical antifungal agents. Therefore, F-RVCZ is considered to be much more cost-effective than topical antifungal agents.

In vitro characterization of self-emulsifying drug delivery system-based lipsticks loaded with ketoconazole

BackgroundSelf-emulsifying system-based lipstick may prove to have the potential of enhancing moisturizing characteristics and delivering hydrophobic drug antifungal drugs for the management of lip fungal infection, especially candidiasis. In this study, the self-emulsifying drug delivery system (SEDDs) of ketoconazole was obtained using IPM (Oil), Tween 80 (surfactant), and PEG 400 (co-surfactant). The medicinal lipstick was developed from the SEDDs, and the concentration of waxes (beeswax and carnauba wax) and cow ghee (penetration enhancer) was optimized using a Box–Behnken design. The lipstick formulations were assessed based on physicochemical features, such as pH, spreadability, softening point, breaking point, content uniformity, and in vitro drug permeation. Furthermore, the optimal lipstick formulation was tested for stability and antifungal activity.ResultsThe optimized formulation showed exceptional results in physicochemical analysis and ~ 87% release of the drug in 12 h. The formulations displayed adequate stability for 4 weeks at various temperature conditions such as room temperature, 40 °C, and 45 °C. The zone of inhibition produced by lipstick formulation was significantly higher as compared to the reference standard (ketoconazole in ethanol) which shows high antifungal activity.ConclusionIt was concluded from the outcomes that SEDDs-based lipstick formulation showed a lot of promise as a topical antifungal treatment option for Candidiasis.Graphical abstract

Formulation and Evaluation of Fluconazole Lotion

In the present work, Fluconazole -SLNs were successfully prepared by high shear homogenization and ultrasonication technique. The results showed that the entrapment efficiency %, zeta potential, zeta size, morphology, thermal character and the in-vitro drug release from Fluconazole -SLNs dispersion and from Fluconazole -SLNs lotion were greatly affected by the type and concentration of surfactant and concentration of the used lipid which affect the in-vitro antifungal character of the prepared Fluconazole -SLNs lotion. The sustained release behavior of Fluconazole -SLNs gel with favorable physicochemical Properties can form a foundation for further clinical studies using these prepared lotions for topical delivery of Fluconazole. Topical treatment of the skin infection has been mainly used due to its eminence over oral treatment to avoid systemic adverse effects, target the site of infection for application of drug formulation and to increase the patient compliance. The vesicular, colloidal and nanoparticulate carriers systems are used for the topical antifungal treatment. A vesicular carrier such as transferosomes and ethosomes has demonstrated as they increased drug transdermal penetration. Formulation of topical product plays a main role for penetration of the drug through skin. Lipophilicity of drug molecules is also effective parameter in physiochemical property. Some antifungal drugs are more lipophilic compounds which affect the penetration of drugs through stratum corneum. Various formulations have emerged, to optimize new drug delivery carriers for antifungal treatment.

Highly Antifungal Activity of Biosynthesized Copper Oxide Nanoparticles against Candida albicans.

Candida albicans (ATCC SC5314) was exposed to biosynthesized copper oxide nanoparticles (CuONPs) to determine their inhibitory capacity. Nanoparticles were polydisperse of small size (5.8 ± 3.5 nm) with irregular shape. The minimum inhibitory concentration (MIC) against C. albicans was 35.5 µg/mL. The production of reactive oxygen species (ROS) of C. albicans was verified when exposed to different concentrations of CuONPs. Ultrastructural analysis of C. albicans revealed a high concentration of CuONPs in the cytoplasm and outside the cell; also, nanoparticles were detected within the cell wall. Cytotoxic analyses using fibroblasts (L929), macrophages (RAW 264.7), and breast (MCF-12) cell lines show good results of cell viability when exposed at the MIC. Additionally, a hemocompatibility analysis was carried out and was found to be below 5%, considered the threshold for biocompatibility. Therefore, it is concluded that the biosynthesized CuONPs have a high potential for developing a topical antifungal treatment.

Antifungal Nail Lacquer for Enhanced Transungual Delivery of Econazole Nitrate.

The fungal disease of the nail, onychomycosis, which is also the most prevalent nail disturbance, demands effective topical treatment options considering the possible adverse effects of systemic antifungal therapy. The current work is focused on development of an adhesive and resistant, drug-delivering and permeation-enhancing polymeric film containing econazole nitrate (ECN) for topical antifungal treatment. The development of the lacquer formulation was guided by the Quality by Design approach to achieve the critical quality attributes needed to obtain the product of desired quality. Eudragit RSPO at 10% w/w was found to be the ideal adhesive polymer for the application and an optimal permeation-enhancing lacquer formulation was achieved by the optimization of other formulation excipients, such as plasticizer and the solvent system. Additionally, novel experimental enhancements introduced to the research included refined D50 drying time and drying rate tests for lacquer characterization as well as a multi-mechanism permeation-enhancing pre-treatment. Moreover, a practical implication was provided by a handwashing simulation designed to test the performance of the lacquer during actual use. In vitro drug release testing and ex vivo nail permeation testing demonstrated that the optimized nail lacquer performed better than control lacquer lacking the permeation enhancer by achieving a faster and sustained delivery of ECN. It can be concluded that this is a promising drug delivery system for topical antifungal treatment of onychomycotic nails, and the novel characterization techniques may be adapted for similar formulations in the future.

P320 Ten cases of tinea incognito due to Trichophyton rubrum, and literature review on the pathogenic characteristics

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMObjectiveWe present ten tinea incognito (TI) patients caused by Trichophyton rubrum combined with a review of the characteristics of tinea incognito infections reported worldwide over the past 20 years, leading to clinical requirements for diagnosis and treatment.Patients and MethodsPatients were scraped for direct KOH microscopy of the skin lesions at the initial visit, isolates were cultured in SDA medium for 14 days and species were identified by morphology and molecular analysis using ITS regions. Literature review by searching articles on ‘PubMed’ and ‘Web of Science’, using the keywords ‘Tinea incognito or Incognito’, Set the year as ‘2002-2022’, and screened the literature for cases with clear types of TI infecting pathogens. Clinical, mycological, and treatment data of all cases were collected and analyzed.ResultsWe report 10 cases of tinea incognito caused by T. rubrum, ranging in age from 5 to 70 years, with clinical manifestations of eczema-like (Figs. 1a, b, and f), SLE-like (Fig. 1d) and pustular psoriasis-like (Figure 1c, e, g, h, i and j), seen in multiple sites. All of our patients had either tinea pedis or onychomycosis themselves or in their family members.A total of 660 cases reported in the last 20 years, T. rubrum (279/660) was the main anthropophilic dermatophytes causing TI, T. mentagrophytes (162/660) and Microsporum canis (135/660) were the common zoophilic pathgens. There were median age differences in patients infected with T. rubrum, T. mentagrophytes, M. canis, and Nannizzia gypsea, at 56, 22.5, 23, and 5.5 years old, respectively (Fig. 2a). The TI patients infected by T. rubrum often had cutaneous or non-cutaneous underlying diseases (27/41), TI patients with zoophilic or geophilic dermatophyte infections had a definite animal or soil contact history (114/136). The face and trunk are the most frequently affected areas, followed by the extremities and the whole body (Fig. 2b). TI appears on the face and is often thought of as eczema, rosacea, DLE, photosensitive rash, and when it occurs on the trunk is misdiagnosed as eczema, pyoderma, psoriasis (Fig. 2c). In Asia and the Americas, anthropophilic dermatophytes are by far the most reported pathogens, especially T. rubrum. In Europe, zoonotic pathogens have been reported in excess of the anthropophilic (Fig. 2d). For patients in whom the nature of the lesions cannot be determined and with negative direct microscopic examination, dermoscopy can be used to aid in the diagnosis. Our review of all cases found that topical or systemic antifungal treatment always gave good efficacy.ConclusionTI has a broad spectrum of mimics, and an unrestricted range of target audiences, zoonotic pathogens are adapting to the human host, so the history of illness and contact is essential at the time of the initial visit. A definitive diagnosis must be obtained in a mycological laboratory, multiple modalities can be used to diagnose TI, and systemic antifungal treatment is often necessary.

Aspergillus wound infection in an immune-competent patient – A case report

• Abdominal surgical site aspergillosis can be seen in an immunocompetent patient. • Surgical site aspergillosis is a form of cutaneous aspergillosis. • Prevention of surgical site aspergillosis combines clinical and environmental considerations. • Therapy involves medical and surgical approach for optimal outcomes. Abdominal aspergillosis is a life-threatening, opportunistic fungal infection that mainly affects immunocompromised patients. In this report, we present a case of abdominal surgical site aspergillosis in an immunocompetent patient. A 74-year-old immune-competent woman that had a prolonged hospitalization in the Intensive Care (ICU) Unit with several abdominal surgeries and multiple antibiotic treatment regimens. The abdomen remained open between interventions. 21 days following ICU admission a diagnosis of surgical site aspergillosis was made, treated with systemic and topical antifungal treatment. While nosocomial aspergillosis typically affects immunocompromised patients, immunocompetent patients also become susceptible when the skin barrier is broken and tissue is exposed to the environment. Treatment consisted with surgical debridement and systemic antifungal therapy. This case provides an example of extensive and rare surgical infection.

Mycotic keratitis due to rare fungal species Neoscytalidium

Neoscytalidium dimidiatum is a plant pathogen that rarely causes human infection. Very few cases of ocular infection have been reported. We report a case series of three patients who presented with keratitis caused by it. The culture showed effuse, white-to-grayish colonies with yellow-to-deep orange colony reverse. Chains of arthroconidia typical of Neoscytalidium were seen on staining with lactophenol cotton blue. Two patients responded to topical antifungal treatment while one needed therapeutic keratoplasty. Hence, early diagnosis and intensive antifungal treatment are essential for successful healing in mycotic keratitis caused by Neoscytalidium species.

Facial Seborrheic Dermatitis in HIV-Seropositive Patients: Evaluation of the Efficacy and Safety of a Non-Steroidal Cream Containing Piroctone Olamine, Biosaccharide Gum-2 and Stearyl Glycyrrhetinate - A Case Series.

Facial seborrheic dermatitis is common in HIV-positive patients, and the presence of facial lesions can affect quality of life. The management and control of lesions can be frustrating for both physicians and patients. In this pilot clinical study, we clinically evaluated the effectiveness of a topical non-steroidal cream in treating mild to moderate facial seborrheic dermatitis in 20 HIV-positive patients. The patients applied a twice-a-day topical cream containing zinc PCA, piroctone olamine, hydroxyphenyl propamidobenzoic acid, biosaccharide gum-2, and stearyl glycyrrhetinate for 12 weeks with no topical or oral antifungal or corticosteroid treatment. Signs and symptoms and tolerance were assessed before, during, and at the end of treatment. All of the patients showed clinical improvement after 4 and 12 weeks of treatment. None of the patients had no response to treatment, and no adverse effects were reported. No rescue therapy with corticosteroids was needed. The patients reported a very noticeable improvement in their skin which contributed to high compliance with the protocol requirement.

Comparative study between topical clotrimazole manufactured by nanotechnology alone and with neodymium‐doped yttrium aluminum garnet laser (1064 nm) compared with neodymium‐doped yttrium aluminum garnet laser alone in the treatment of onychomycosis

Background Onychomycosis is defined as a fungal infection of the nail. It is caused by dermatophytes, nondermatophytes, and yeasts. Nanosuspension is defined as a submicron colloidal dispersion of any of the drug particles. Neodymium‐doped yttrium aluminum garnet (Nd : YAG) laser has been reported to be effective for treating onychomycosis. The aim was to compare topical clotrimazole-loaded gel alone and with Nd : YAG laser compared with Nd : YAG laser only in patients with mycologically proven onychomycosis. Patients and methods A total of 60 patients presented with onychomycosis. All patients were subjected to a full history taking, dermoscopic and clinical examination, assessment of severity by using the onychomycosis severity index, and culture. Results There was a statistically significant response (decrease in onychomycosis severity index, dermoscopic features, and mycological clearance) in patients treated by both topical clotrimazole and Nd : YAG laser compared with laser alone or topical clotrimazole-loaded gel alone. Conclusion Clotrimazole-loaded gel showed high efficacy against Candida and can be used as an adjuvant to systemic or topical antifungal treatment for onychomycosis or laser system.

English

BACKGROUND Treatment of fungal ulcers is one of the most challenging tasks. Various topical antifungal drugs have poor corneal stromal penetration. Voriconazole is a broad spectrum drug and is an effective agent for the treatment of fungal keratitis as a topical preparation. It is potent against a broad range of clinically significant fungal infections both in the eye as well systemically. In tropical climatic conditions filamentous fungi commonly cause eye infections and are associated with poor visual outcomes. The treatment options for mycotic ulcers are limited, therefore direct intrastromal injections are helpful in the management of these deep mycotic keratitis. We wanted to evaluate the role of intrastromal injection of voriconazole in the management of deep fungal keratitis not responding to conventional therapy. METHODS This an interventional case series study done at a tertiary care centre in south India from the year April 2019 to August 2020. Eight eyes of eight patients with microbiologically proven deep stromal recalcitrant mycotic keratitis not responding to topical antifungal medications were evaluated. Voriconazole 50 microgram / 0.1 ml was injected around the infiltrate in the corneal stroma as an adjunctive to the topical antifungal treatment. Main outcome measure was a reduction of the size of the infiltrate and ulcer and decrease in infection on regular follow ups. RESULTS Before injecting voriconazole, all the cases were of either gradually worsening of lesions on topical treatment, or not responding to topical treatment. After the injection a rapid decrease in the size of corneal ulcer, hypopyon, and infiltration was seen within 3 weeks. CONCLUSIONS Targeted delivery of intrastromal voriconazole may be a safe and effective way in the management of deep seated fungal ulcers which respond poorly to conventional treatment procedures, thus reducing the need for further surgical treatment. KEYWORDS Intrastromal Injection, Voriconazole, Fungal Keratitis, Deep Mycotic Keratitis

Clinical Characteristics, Histopathology, and Treatment Outcomes of Pythium Keratitis: A Retrospective Cohort Study.

PurposeTo identify factors associated with the prognosis in Pythium keratitis.Patients and MethodsThe medical records of 25 patients (26 eyes) diagnosed with Pythium keratitis at a referral institution were reviewed. The demographic and clinical characteristics, treatment, microbiological diagnosis, histopathological features, and outcomes were recorded. The histopathological specimens were reviewed. The patients were divided into a globe removal group and a globe salvage group. Univariate analysis was used to identify factors associated with poor outcomes.ResultsFifteen eyes (57.7%) were removed. Patients in the globe removal group were on average 16.4 years older (95% CI 6.98 to 25.88) than those in the globe salvage group, received the first medication (either topical antifungals or antibiotics) later than one day after the onset of symptoms (RR = 2.75, 95% CI 1.18 to 6.42), and had a maximal diameter of the infiltration area ≥6 mm (RR = 3.14, 95% CI 1.17 to 8.45). The globe removal group showed satellite, multifocal, or total corneal infiltration patterns (RR = 2.82, 95% CI 1.03 to 7.74) and a hypopyon (RR = 3.43, 95% CI 1.26 to 9.35) as risk factors. The histopathological examination showed a higher density of Pythium in the globe removal group than the globe salvage group (median 376 (interquartile range 323, 620) versus 107 (interquartile range 16, 260) hyphae per high power field; P = 0.035).ConclusionThe risk of globe removal in patients with Pythium keratitis increased with age, delayed initial topical antifungal or antibiotic treatment, advanced disease at presentation, and dense Pythium hyphae infiltration of the cornea. Early recognition and treatment are critical to successfully eradicate the infection.

Comparative study between the effect of topical tazarotene 0.1 gel alone vs its combination with tioconazole nail paint in treatment of onychomycosis.

Onychomycosis (OM) is a chronic fungal infection of the nail caused by dermatophytes, yeasts, and nondermatophytes. Tioconazole is one of the topical antifungal belonging to imidazole derivatives. Tazarotene is a synthetic retinoid, with immunomodulating properties and anti-inflammatory activity. To evaluate the efficacy of tazarotene 0.1% gel alone in comparison with its combination with tioconazole nail paint in the treatment of onychomycosis. Forty patients presented with onychomycosis, subjected to a full history taking, clinical examination, and nail examination, which includes a clinical, dermoscopic, assessment of severity by using Onychomycosis Severity Index (OSI), KOH examination, and fungal culture. There was a statistically significant increase in the response of treatment in patients treated by a combination of tazarotene and tioconazole compared to tazarotene alone through (decrease in OSI, dermoscopic features, and mycological clearance). Tazarotene had antifungal activity specially against Aspergillus niger while its combination with tioconazole gave better results and can be used as an adjuvant to the standard systemic or topical antifungal treatment for OM.

Oral versus topical antifungal treatment for recurrent vulvovaginal candidiasis

Objective To evaluate the effect of using oral versus topical antimycotic preparations in treatment of recurrent vulvovaginal candidiasis. Background Vaginal candidiasis is a common disease in women during their lifetime. Although several antifungal drugs are routinely used for treatment, recurrent vaginal candidiasis is a challenge for patients and gynecologists. Patients and methods This was a randomized control trial that included 88 cases complaining of recurrent vaginal candidiasis, with occurrence ranging from 4 to 8 episodes/year, with confirmed clinical and mycological diagnosis of vaginal candidiasis. Patients were divided into two groups by randomized number sequence: group A received oral fluconazole and group B received local clotrimazole vaginal tablets. This trial was conducted at the Department of Obstetrics and Gynecology, Zawyet Aal-Naoora Hospital, in Menoufia from March 2017 to June 2018. Results This study revealed a total clinical cure rate of 81% for fluconazole group and 76.1% for clotrimazole group. Total mycological cure rate was 80.5% for group A and 77.3% for group B. There was no statistically significant difference regarding clinical or mycological cure rates in all visits between the two groups. The most frequent adverse effect in group A was nausea and for group B was vaginal burning sensation. Conclusion Response to treatment of recurrent vulvovaginal candidiasis was similar among fluconazole and long-term use of clotrimazole vaginal tablets.

The combined utilization of Chlorhexidine and Voriconazole or Natamycin to combat Fusarium infections

BackgroundFusarium species are the fungal pathogens most commonly responsible for the mycotic keratitis, which are resistant to the majority of currently available antifungal agents. The present study was designed to assess the efficacy of a combination of low doses chlorhexidine with two other commonly used drugs (voriconazole and natamycin) to treat Fusarium infections.ResultsWe utilized combinations of chlorhexidine and natamycin or voriconazole against 20 clinical Fusarium strains in vitro using a checkerboard-based microdilution strategy. In order to more fully understand the synergistic interactions between voriconazole and chlorhexidine, we utilized a Galleria mellonella model to confirm the combined antifungal efficacy of chlorhexidine and voriconazole in vivo. We found that for voriconazole, natamycin, and chlorhexidine as single agents, the minimum inhibitory concentration (MIC) ranges were 2–8, 4–16, and > 16 μg/ml, respectively. In contrast, the MIC values for voriconazole and chlorhexidine were reduced to 0.25–1 and 1–2 μg/ml, respectively, when these agents were administered in combination, with synergy being observed for 90% of tested Fusarium strains. Combined chlorhexidine and natamycin treatment, in contrast, exhibited synergistic activity for only 10% of tested Fusarium strains. We observed no evidence of antagonism. Our in vivo model results further confirmed the synergistic antifungal activity of chlorhexidine and voriconazole.ConclusionsOur results offer novel evidence that voriconazole and chlorhexidine exhibit synergistic activity when used to suppress the growth of Fusarium spp., and these agents may thus offer value as a combination topical antifungal treatment strategy.

Tinea corporis: an updated review.

BackgroundTinea corporis is a common fungal infection that mimics many other annular lesions. Physicians must familiarize themselves with this condition and its treatment.ObjectiveThis article aimed to provide a narrative updated review on the evaluation, diagnosis, and treatment of tinea corporis.MethodsA PubMed search was performed with Clinical Queries using the key term ‘tinea corporis.’ The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies, and reviews. The search was restricted to the English language. The information retrieved from the mentioned search was used in the compilation of the present article.ResultsTinea corporis typically presents as a well-demarcated, sharply circumscribed, oval or circular, mildly erythematous, scaly patch or plaque with a raised leading edge. Mild pruritus is common. The diagnosis is often clinical but can be difficult with prior use of medications, such as calcineurin inhibitors or corticosteroids. Dermoscopy is a useful and non-invasive diagnostic tool. If necessary, the diagnosis can be confirmed by microscopic examination of potassium hydroxide wet-mount preparations of skin scrapings from the active border of the lesion. Fungal culture is the gold standard to diagnose dermatophytosis especially if the diagnosis is in doubt and results of other tests are inconclusive or the infection is widespread, severe, or resistant to treatment. The standard treatment of tinea corporis is with topical antifungals. Systemic antifungal treatment is indicated if the lesion is multiple, extensive, deep, recurrent, chronic, or unresponsive to topical antifungal treatment, or if the patient is immunodeficient.ConclusionThe diagnosis of tinea corporis is usually clinical and should pose no problem to the physician provided the lesion is typical. However, many clinical variants of tinea corporis exist, rendering the diagnosis difficult especially with prior use of medications, such as calcineurin inhibitors or corticosteroids. As such, physicians must be familiar with this condition so that an accurate diagnosis can be made and appropriate treatment initiated.

An update on pityrosporum folliculitis in Singapore from a single tertiary care dermatological centre.

Pityrosporum folliculitis (PF) is a common skin condition that can be easily misdiagnosed, especially by non-dermatologists. While the initial diagnosis is often made clinically, skin microscopy may help to confirm the same. However, there is scant literature regarding the clinical epidemiology of PF. To our knowledge, in Singapore, only one prior epidemiological study was performed in 1987. Through the present study, we aimed to provide an update regarding the epidemiology, diagnosis and treatment of patients with PF in Singapore. We performed a retrospective review of patients with clinical presentations compatible with PF who presented to the dermatology clinic at the National University Hospital, Singapore, between 1 January 2011 and 31 December 2015. The medical records of patients identified as having clinical presentations that resembled PF were reviewed via written and electronic databases. Information regarding the demographics and clinical presentation of the patients was collected. Of the 375 patients identified, 214 (57.1%) were confirmed as having PF based on Gram-stain microscopy. Most (35.0%) of these 214 patients were aged between 21 and 30 years, with a male-to-female ratio of 3:1. The lesions predominantly occurred on the trunk and the back. The majority of patients presented with symptoms that lasted more than one month. 128 (59.8%) patients received oral antifungal treatment, whereas 82 (38.3%) patients were treated with topical antifungal treatment alone. A typical Singapore patient with PF is a young man aged 21-30 years, with erythematous follicular papules or pustules over the trunk and the back.