Topical Antifungal Treatment Research Articles

In vitro susceptibility profile of 200 recent clinical isolates of Candida spp. to topical antifungal treatments of vulvovaginal candidiasis, the imidazoles and nystatin agents

Topical antifungal treatment of vulvovaginal candidiasis is widely recommended. The most commonly recommended topical antifungals (the imidazoles clotrimazole, miconazole and econazole and the polyene nystatin) have been on the market for more than 30 years. There are only a few recent data available on the susceptibility of different Candida species to these antifungals, especially of non-albicans Candida species which appear to be less responsive to treatment with imidazoles. The study aimed to determine the in vitro susceptibility profile of a large number of recent clinical isolates of Candida spp. to the most commonly recommended topical antifungals. An antifungal susceptibility test was performed according to the CLSI M27-A3 broth microdilution method, and minimal inhibitory concentrations were determined for econazole, miconazole, clotrimazole and nystatin. The clinical isolates comprised of: 113 Candida albicans, 54 Candida glabrata, 11 Candida krusei, 11 Candida tropicalis and 11 Candida parapsilosis. The three azoles agents exhibited MIC90 values of 0.06 mg/L against C. albicans isolates, while nystatin exhibited a MIC90 of 4 mg/L. For non-albicans Candida isolates, MIC90 values ranged from 0.5 to 8 mg/L, from 1 to 4 mg/L and from 0.12 to 4 mg/L, for econazole, miconazole, clotrimazole, respectively. Nystatin MIC90 remained at 4 mg/L for all non-albicans Candida species tested. These results confirmed the susceptibility of C. albicans to the most frequently used topical agents and may support the use of alternative agents to imidazoles, such as nystatin, to treat vulvovaginal candidiasis caused by non-albicans Candida species.

Series of Five Cases of Papulaspora equi Keratomycosis

The aim of this study was to describe a case series of Papulaspora equi keratomycosis, with clinical and laboratory characteristics of an organism that has not been reported from scrapings of corneal ulcers from humans. This is a retrospective chart review of 5 patients whose diagnostic corneal scrapings had grown P. equi on culture between 2008 and 2013. The clinical presentation, diagnostic tests, management, and the outcome of the ulcers are described. All patients showed characteristic features of fungal corneal ulcers on clinical examination. Only 2 of the 5 patients reported having a history of injury to their eyes. One patient showed surface pigmentation that could mimic a dematiaceous ulcer. All the patients responded to topical antifungal treatment with 5% natamycin or prepared 2% ketoconazole drops. Corneal ulcers may be caused by rare organisms, as in our series of patients who had P. equi keratomycosis, a hitherto unreported human pathogen. All the patients responded to treatment with conventional topical antifungal medications.

Elastosis Perforans Serpiginosa

Elastosis perforans serpiginosa is a rare skin disease characterized by transepidermal elimination of abnormal elastic fibers. This condition classically presents as small papules arranged in serpiginous or annular patterns on the neck, face, arms, or other flexural areas. While these lesions may spontaneously resolve, they often persist for longer periods of time. Though numerous treatment modalities have been described in the literature, most are not very effective. A 35-year-old man presented to Gangnam Severance Hospital with a 2-year history of skin eruptions on his neck, which were refractory to topical antifungal or steroid treatment. On examination, the patient showed multiple crusted and erythematous papules arranged in an annular pattern with central clearing. A biopsy specimen revealed acanthosis with notable transepidermal elimination of nuclear debris and eosinophilic degenerated elastic fibers from the dermis via an epidermal channel. Verhoeff-van Gieson staining showed dense clumps of altered elastic fibers in the papillary dermis. Based on these findings, a diagnosis of elastosis perforans serpisinosa was made. Treatment with topical 0.05% tretinoin application for 6 months resulted in no improvement.

Use of topical nasal therapies in the management of Chronic rhinosinusitis

To determine whether the use of topical nasal therapies with saline alone and in combination with antibiotics, antifungals, or corticosteroids is effective in the treatment of patients with chronic rhinosinusitis (CRS). A systematic literature search was performed utilizing the MEDLINE database (1966 to May 2012), EMBASE database (1980 to May 2012), and the Cochrane Central Register of Controlled Trials. Electronic databases were searched by three otolaryngologists. Studies on five major categories of topical nasal therapies searched included saline (hypotonic, isotonic and hypertonic); topical antibiotics, topical steroids, and topical antifungals were obtained. Randomized controlled trials and meta-analyses of randomized controlled trials were included. Sixteen randomized controlled trials were identified examining topical saline (hypertonic or isotonic) in CRS patients. Two randomized controlled trials were found studying the effect of topical antibiotics in patients with CRS. Four randomized controlled trials were identified studying topical antifungal treatment for CRS. Twenty-five randomized controlled trials were found studying topical steroids in CRS patients. A high aggregate quality of evidence supports the effectiveness of saline irrigations in treating CRS. There is insufficient evidence to support a clear benefit of topical antibiotics in patients with chronic rhinosinusitis. Topical antifungal therapies have not been shown to be significantly different in efficacy than saline controls on CRS outcomes. Topical steroids are beneficial in the treatment of CRS with nasal polyps, but have not been shown to be effective in CRS without nasal polyps.

Efficacy, Safety and Tolerability of an Optimized Avulsion Technique with Onyster® (40% Urea Ointment with Plastic Dressing) Ointment Compared to Bifonazole-Urea Ointment for Removal of the Clinically Infected Nail in Toenail Onychomycosis: a Randomized Evaluator-Blinded Controlled Study

Background: Toenail onychomycosis is highly prevalent, with 14-28% of people aged 60 or over suffering from the disease. Use of a topical antifungal alone in toenail onychomycosis is associated with low cure rates. This may be due to limited penetration of the topical antifungal through the diseased nail. The objective of the present study was to compare two treatment modalities to obtain diseased nail chemical avulsion in toenail onychomycosis. Methods: In this European, multicenter, randomized, parallel-group, open-label, active-controlled study, male or female adult patients with distal-lateral or lateral subungual dermatophyte onychomycosis on at least 12.5% of the great toenail were randomized either to a 40% urea ointment with plastic dressing group (n = 53) or to a bifonazole-urea ointment group (n = 52). The ointments were applied daily for a maximum of 3 weeks according to the summary of product characteristics. After assessment of infected nail debridement, topical antifungal treatment with bifonazole cream was applied daily in both groups for 8 weeks. 102 patients were evaluated, i.e. 51 in the 40% urea ointment with plastic dressing group and 51 in the bifonazole-urea group. The primary end point was complete removal of the nail plate at day 21 (D21). Secondary end points were: complete cure and mycological cure evaluated at D105. Ease of use and local tolerability were also assessed. Results: Complete removal of the clinically infected target nail plate area, assessed by blinded evaluators, was significantly higher in the 40% urea ointment with plastic dressing group (61.2%) than in the control group (39.2%), showing the superiority of 40% urea ointment with plastic dressing (p = 0.028). The same results were observed in the per-protocol population (63.0 vs. 36.6%; p = 0.014). Complete removal of the infected area assessed by the investigator at D21 showed a significantly higher success rate in patients treated with 40% urea ointment with plastic dressing (86.3%) as compared to patients treated with bifonazole-urea (60.8%), confirming the superiority of 40% urea ointment with plastic dressing (p = 0.004). At D105, the complete cure of onychomycosis, a criterion combining clinical and mycological assessments, showed a success rate of 27.7% for 40% urea ointment with plastic dressing versus 20.8% for the control group. No statistical difference was observed between the two treatment groups. The number of patients with at least one adverse event was twice as high in the bifonazole-urea group in comparison to the 40% urea ointment with plastic dressing group. Overall assessment of local tolerability by the investigator was considered good/very good in 98.0% of the 40% urea ointment with plastic dressing patients versus 90.4% of the bifonazole-urea patients, at D21, with no significant difference between both groups. Conclusion: This study shows the superiority of 40% urea ointment with plastic dressing to bifonazole-urea ointment for complete removal of the infected target nail assessed by blinded evaluators and by the investigators. Further studies are needed to assess the impact of preliminary chemical nail avulsion on the efficacy of topical treatment of onychomycosis as assessed by complete cure at 1 year.

Bilateral Fusarium oxysporum keratitis after laser in situ keratomileusis

We report the successful management of a rare case of bilateral post-laser in situ keratomileusis (LASIK) Fusarium oxysporum keratitis and propose a therapeutic strategy. A 19-year-old white man with no systemic diseases was referred to our emergency service 3 days after microkeratome-assisted myopic bilateral LASIK correction. He complained of blurred-vision, photophobia, and ocular pain. Clinical findings (satellite lesions, hypopyon) suggested fungal keratitis. Flaps were immediately lifted and rinsed with povidone-iodine 10%, and intensive topical and systemic and combined antifungal and antibacterial treatment was introduced. Topical cortisone drops were administered after 3 days. Despite initial deterioration of the clinical picture, all symptoms resolved quickly. Polymerase chain reaction indicated F oxysporum. Relapse occurred in the left eye, which was successfully managed. The final uncorrected distance visual acuity was 20/20 in both eyes. Fusarium oxysporum post-LASIK keratitis may occur in the early phase. Prompt diagnosis, interface irrigation with povidone-iodine solution, and intensive long-term treatment contribute to a favorable outcome. No author has a financial or proprietary interest in any material or method mentioned.

Improvement in onychomycosis after initiation of combined antiretroviral therapy

Onychomycosis is frequent in patients with late and advanced HIV disease; immunocompromised patients may develop atypical clinical presentations that can be difficult to control. Current treatment for onychomycosis is based on the prolonged administration of antifungal therapies that may have significant interactions with combined antiretroviral therapy (cART). An improvement in certain HIV-associated opportunistic infections has been associated with initiation of cART. The aim of this study was to analyze the influence of cART on the outcome of onychomycosis in HIV-infected patients. HIV-infected patients with dermatologic lesions attending the National Institute of Respiratory Diseases were asked to undergo physical examination. Detailed clinical histories were recorded. Routine laboratory tests, CD4 T cell count, and HIV viral load were performed. Onychomycosis was diagnosed on the basis of clinical appearance. Nail scrapings were collected from toenails and fingernails. Specimens were analyzed using direct microscopy. Nail changes after cART initiation were assessed by clinical examination. Improvement in onychomycosis was observed in six patients with late and advanced HIV disease after initiation of cART. Complete resolution of onychomycosis was observed in one patient without the use of antifungal therapy; one patient required topical antifungal treatment, and two patients required systemic antifungal treatment to achieve complete resolution. Onychomycosis should be included in the group of pathologies that improve with cART-induced immune reconstitution. The pathogenesis of onychomycosis in HIV disease warrants investigation in the context of cell-mediated immunity restoration.

Topical and systemic antifungal therapy for the symptomatic treatment of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is an inflammatory disorder of the nose and sinuses. Since fungi were postulated as a potential cause of CRS in the late 1990s, there has been increasing controversy about the use of both topical and systemic antifungal agents in its management. Although interaction between the immune system and fungus has been demonstrated in CRS, this does not necessarily imply that fungi are the cause of CRS or that antifungals will be effective its management. To assess the effectiveness of topical or systemic antifungal therapy in the treatment of CRS. We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 8 March 2011. All randomised, placebo-controlled trials considering the use of topical or systemic antifungal therapy in the treatment of CRS and allergic fungal sinusitis (AFS). CRS was defined using either the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) or American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) criteria. We reviewed the titles and abstracts of all studies obtained from the searches and selected trials that met the eligibility criteria. We extracted data using a pre-determined data extraction form. There was significant heterogeneity of outcome data reporting with reports containing both parametric and non-parametric representations of data for the same outcomes. Means and standard deviations for change data were unavailable for a number of trials. Due to the limited reported data, we contacted authors and used original data for data analysis. Six studies were included (380 participants). Five studies investigated topical antifungals and one study investigated systemic antifungals. The risk of bias in all included studies was low, with all trials being double-blinded and randomised. Pooled meta-analysis showed no statistically significant benefit of topical or systemic antifungals over placebo for any outcome. Symptom scores in fact statistically favoured the placebo group. Adverse event reporting was statistically significantly higher in the antifungal group. On the basis of this meta-analysis, there is no evidence to support the use of either topical or systemic antifungal treatment in the management of CRS.

Compliance of the patients and related influential factors on the topical antifungal treatment of onychomycosis

To explore the compliance rate of patients and its influential factors on topical antifungal treatment of onychomycosis. Dermatology life quality index (DLQI) and self-administered questionnaires were employed in this study. The overall compliance rate of the topical antifungal treatment was 23.9% (92/385). The cure rates on onychomycosis in patients with good compliance was 63.04% (58/92), but only 2.05% (6/293) in those noncompliant patients, respectively. Regarding the influencing factors as age, sex, level of awareness, occupation, course of disease, personal income, inconvenience in access to the treatment, keep forgetting in taking the medicine, being impatient, lack of confidence, misunderstanding on topical as 'dirty' and the process of drug taking was troublesome, together with the quality of life were identified. There were significant differences between those compliant or noncompliant patients. For some factors as adverse effects of drug, number of affected nails, site of the disease, too busy in daily life, lack of related knowledge etc., no significant differences were found between the compliant or noncompliant patients. Our results showed that onychomycosis patients had poor compliance in topical antifungal treatment which significantly influencing the therapeutic effects. Age, sex, level of awareness on the disease, occupation, course of disease, personal income, inconvenience in receiving the treatment, forgetting to take the medicine, lack of patience, lack of confidence, different kinds of misunderstanding about the disease and quality of life etc. might affect the compliance rate of the disease.

Fungicidal and Bactericidal Properties of Bisabolol and Dragosantol

α-Bisabolol, a natural plant sesquiterpene alcohol, and dragosantol, a racemic mixture of synthetic bisabolol, were studied for their fungicidal properties separately against the nongerminated and germinating conidia of several species of Aspergillus and Fusarium which represent problems in agriculture and medicine. Bactericidal assays against Pseudomonas aeruginosa and Staphylococcus aureus were also performed. Compared to the controls, both compounds displayed statistically significant (p < 0.001) lethality for the tested microorganisms. α-Bisabolol and dragosantol produced nearly 98% viability loss against the germinating conidia of A. flavus, A. fumigatus, A. niger, A. terreus, F. oxysporum, F. solani, and F. verticillioides (formerly F. moniliforme) at, or below, 10 μM. The viability of nongerminated F. oxysporum conidia was significantly reduced. Both compounds showed very rapid and significant reduction of P. aeruginosa viability at 7.5 μM. Staphylococcus aureus was more resistant to these compounds though significant viability loss occurred after 2 h incubation at 12.5 μM. Minimum inhibition concentration studies (NCCLS Method-38A) showed that bisabolol inhibited the growth of clinical isolates of the dermatophytic pathogens Trichophyton tonsurans (2–8 μg/mL), T. mentogrophytes (2–4 μg/mL), T. rubrum (0–1 μg/mL) and Microsporum canis (0.5–2.0 μg/mL). Results showed α-bisabolol and dragosantol have potent fungicidal and bactericidal properties against the tested strains. Because both compounds are safe for use in cosmetics, the data presented here suggest potential utility as antimicrobials in cosmetics, food and as a topical antifungal treatment

New Approaches to Candida and Oral Mycotic Infections

This workshop reviewed aspects of the following: oral fungal disease in HIV-infected patients and the predictive value of oral mucosal disease in HIV progression; the role of the oral biofilms in mucosal disease; microbial virulence factors and the pseudomembranous oral mucosal disease process; the role that oral mucosal disease may have in HIV transmission; and the available topical antifungal treatment. This article summarizes the ensuing discussions and raises pertinent problems and potential research directions associated with oral fungal disease in HIV-infected patients, including the frequency of oral candidosis, the role of the intraoral biofilm in the development of oral mucosal disease, and host-pathogen interactions, as well as the development of the fetal oral mucosa, neonatal nutrition, and the role of oral candidosis in this setting. Finally, discussions are summarized on the use of inexpensive effective antifungal mouthwashes in resource-poor countries, the potential stigmata that may be associated with their use, as well as novel topical medications that may have clinical applicability in managing oral candidal infections in HIV-infected patients.

Common Features of Periocular Tinea

To present the common features of periocular tinea to aid physicians in future diagnosis and therapy of this condition, because superficial fungal infections on the face are often misdiagnosed owing to the diverse morphologies that they manifest. This is especially true of dermatophytoses involving the periocular region. A retrospective review was performed of patients with a diagnosis of periocular tinea who were seen between January 2003 and September 2009 in the pediatric dermatology clinic at St. Louis Children's Hospital. Ten cases of periocular tinea were identified (6 male patients and 4 female patients). Common features included prolonged misdiagnosis (all 10 cases), a normal ophthalmologic examination (all 10 cases), and inappropriate corticosteroid application (7 cases). Loss of the eyelashes occurred in all 10 patients. No cases had evidence of other tinea infections on examination. Only 2 cases had the central clearing classically associated with tinea corporis. Seven patients had a potassium hydroxide preparation and/or culture positive for fungal elements. Lesions improved with topical and oral antifungal treatment in all cases, and patients were able to regrow their eyelashes. Periocular tinea should be considered in the differential diagnosis for periocular inflammation, especially in those patients refractory to therapy for more common conditions. Loss of the eyelashes is characteristic of these fungal infections, similar to the hair loss that occurs in kerions associated with tinea capitis.

Contact-Lens Associated Simultaneous Fusarium and Acanthamoebia Keratitis Treated with Therapeutic Penetrating Keratoplasty

Purpose:To report concurrent Fusarium and Acanthamoeba keratitis associated with contact lens wear and treated with penetrating keratoplasty Methods: A 27 year old woman, presented with a 7 day history of pain, watering and foreign-body sensation in her left eye in the setting of monthly disposable contact lens wear and swimming with lenses in situ. She had been self-treating with combination dexamathasone 0.1% and tobramycin 0.3% drops (Tobradex®). Slit-lamp examination revealed a 1.0 x 1.0 millimetre corneal ulcer with underlying infiltration. Corneal scrapes were performed and hourly Ofloxacillin 0.3% drops commenced. Initially symptoms and signs improved but worsened a week later. The scrapings grew Aspergillus fumigates and she was then referred to the corneal service. Results: At this stage a central stromal infiltrate was observed with surrounding satellite infiltrates. The cornea was re-scraped (as it was felt the Aspergillus culture was the result of a contaminant) and the patient was commenced on hourly Econazole 1% drops and systemic Voriconazole. Three days later, the second scrapings grew Acanthamoeba polyphagia. Intensive Brolene and Polihexamide drops were commenced, in addition to the systemic and topical antifungal treatment. Despite treatment, symptoms and signs of keratitis worsened, vision reduced to light perception and 4 weeks later she underwent a left therapeutic keratectomy. Histological examination of the corneal button revealed fungal hyphae and culture grew Fusarium. Topical anti-protozoal and antifugal therapy and systemic Vorconazole were continued for 8 weeks. Six months following keratoplasty the corneal graft remains clear on a reducing dosage of topical dexamethasone 0.1% with a best corrected visual acuity of 20/30. Conclusion: Concurrent Fusarium and Acanthamoeba keratitis may occur in the setting of contact lens wear and their misuse. Despite intensive appropriate topical and systemic therapy the condition worsened but remained central in location and following therapeutic penetrating keratoplasty resolved.

Influence of topical antifungal drugs on ciliary beat frequency of human nasal mucosa

Topical antifungal treatment is a subject of discussion in the treatment of chronic rhinosinusitis. The aim of this research was to study the effects of antifungal drugs on ciliary beat frequency (CBF) of human nasal mucosa under in vitro conditions. Case series of in vitro experiments and in vitro study of cultured ciliated cells of human nasal mucosa. Human nasal mucosa was acquired during routine endoscopic sinus surgery. Cells were cultivated on object slides and exposed to different antifungal drugs in a newly developed test system. This system allowed continuous and reproducible exposure to different drugs at constant temperature, pH value, and osmolarity. The drugs were amphotericin B in two different concentrations and itraconazole. Rinsing with higher concentrations of amphotericin B led to an immediate decrease of CBF, with a total stop after 15 minutes. A different result was seen in the group with lower concentrations; CBF decreased again quickly after rinsing with the test drug, but all of them recovered after rinsing with neutral solution. When using itraconazole a decline in CBF was observed again; one half of the samples returned to activity. Our in vitro results demonstrate a dose-dependent effect of the antifungal drugs amphotericin B and itraconazole on ciliary beat frequency of human nose epithelium.

Efficacy of terbinafine compared to lanoconazole and luliconazole in the topical treatment of dermatophytosis in a guinea pig model

The in vivo efficacy of terbinafine was compared to lanoconazole and luliconazole in the topical treatment of dermatophytosis caused by Trichophyton mentagrophytes using a guinea pig model. Topical antifungal treatment commenced three days post-infection, and each agent was applied once daily for seven consecutive days. Upon completion of the treatment period, evaluations of clinical and mycological efficacies were performed, as was scanning electron microscopy (SEM) analyses. Data showed that while all tested antifungals demonstrated significant mycological efficacy in terms of eradicating the fungi over untreated control, terbinafine and luliconazole showed superior clinical efficacy compared to lanoconazole (P-values < 0.001 & 0.003, respectively). Terbinafine demonstrated the highest clinical percent efficacy. SEM analysis revealed hairs from terbinafine and lanoconazole-treated animals had near complete clearance of fungi, while samples from luliconazole-treated animals were covered with debris and few conidia. This study demonstrates that, in general, terbinafine possessed similar efficacy to lanoconazole and luliconazole in the treatment of dermatophytosis. Terbinafine tended to have superior clinical efficacy compared to the azoles tested, although this difference was not statistically significant against luliconazole. This apparent superiority may be due to the fungicidal activity of terbinafine compared to the fungistatic effect of the other two drugs.

Tinea of vellus hair: an indication for systemic antifungal therapy

Topical antifungal treatment is indicated in tinea of glabrous skin, except in cases of extensive, multiple or recurrent lesions, or immunocompromised patients. However, in daily practice there are cases resistant to topical treatment despite these indications. Parasitism of the hair could be the cause behind the majority of isolated lesions of ringworm of hairless skin with a poor outcome with topical antifungal treatment. To present a prospective observational study of 13 cases of tinea of glabrous skin with topical antifungal resistance during the period 2007-2009. Cases were analysed from a clinical, mycological and therapeutic standpoint. The mean age was 7 years. Eight (62%) patients reported prior contact with an animal and 10 (77%) patients had received topical corticosteroids before visiting the dermatologist. Excoriation was observed in eight (62%) patients, and follicular micropustules were seen in 11 (85%). In all patients, some short thin hairs fell easily on to the slide during the skin scraping. In all patients all the few vellus hairs identified in direct examination were affected. All identified species were zoophilic or geophilic. All cases resolved after oral antifungal treatment. In tinea of glabrous skin with low response to topical antifungal treatment we must rule out tinea of the vellus hair. Infection by nonanthropophilic dermatophytes, previous corticosteroid therapy and excoriation might be predisposing factors. Parasitism of the vellus hair, observed by direct microscopy, should be another criterion for establishing systemic treatment from the onset, as is the case in tinea capitis.

Risk Factors, Clinical Features, and Outcomes of Recurrent Fungal Keratitis after Corneal Transplantation

To study the risk factors, clinical features, and treatment of recurrent fungal keratitis after corneal transplantation. Retrospective, interventional case series. Eight hundred ninety-nine patients (eyes) with fungal keratitis who underwent corneal transplantation at the Shandong Eye Institute between January 2000 and October 2008. Six hundred fourteen patients underwent penetrating keratoplasty (PK) and 285 patients underwent lamellar keratoplasty (LK). All patients failed to respond to topical and systemic antifungal drugs treatment before corneal transplantation. A trephine that was 0.5 mm larger in diameter than the infection area was used during PK or LK. Medical records of each patient were reviewed retrospectively. The species of pathogenetic fungi causing recurrence were analyzed. The clinical features, including recurrence time, position, symptom, and physical signs, were summarized. Based on clinical features, appropriate topical and systemic antifungal treatment was determined for all patients; some patients also received combined subconjunctival or intracameral injection of fluconazole. If there was treatment failure, a conjunctival flap or keratoplasty was performed. Species of pathogenetic fungi, clinical features, and apparent therapeutic effects. Fifty-seven patients (6.34%) experienced recurrence after corneal transplantation. There was no difference between PK (6.79%) and LK (5.96%) in recurrence rate (P = 0.883). A higher rate of recurrences was found in those with preoperative hypopyon (10.90%), corneal perforation (12.00%), corneal infection expanding to limbus (20.69%), or lens infection with extracapsular cataract extraction (50%; P<0.05). The 3 main kinds of recurrence were: (1) recurrent infection from recipient bed to graft, and once recurrent infection invaded the graft, the inflammation progressed more rapidly; (2) white mushroom-shaped hypopyon with anterior chamber recurrence; (3) infection in the posterior chamber and vitreous opacity on posterior segment recurrence. Location of recurrence was: recipient bed (70.18%), anterior chamber (7.02%), and posterior segment (22.81%). The overall cure rate was 82.46%, which included drug therapy (28.07%) and surgical treatment (54.39%). Hypopyon, corneal perforation, corneal infection expanding to limbus and lens infection are major risk factors for recurrence of fungal keratitis after corneal transplantation. Based on the clinical features of recurrence, appropriate treatment options can help to control the recurrent infection.

In vitroactivity of voriconazole against Mexican oral yeast isolates

Oral candidiasis is the most prevalent complication in HIV-infected and AIDS patients. Topical antifungal treatment is useful for the initial episodes of oral candidiasis, but most patients suffer more than one episode and fluconazole or itraconazole can help in the management, and voriconazole may represent a useful alternative agent for the treatment of recalcitrant oral and oesophageal candidiasis. The aim of this research was to study the in vitro activity of voriconazole and fluconazole against Mexican oral isolates of clinically relevant yeast. The in vitro susceptibility of 187 oral yeast isolates from HIV-infected and healthy Mexicans was determined for fluconazole and voriconazole by the M44-A disc diffusion method. At 24 h, fluconazole was active against 179 of 187 isolates (95.7 %). Moreover, a 100% susceptibility to voriconazole was observed. Voriconazole and fluconazole are highly active in vitro against oral yeast isolates. This study provides baseline data on susceptibilities to both antifungal agents in Mexico.

Candida albicans in patients with oronasal communication and obturator prostheses

Patients using obturator prostheses often present denture-induced stomatitis. In order to detect the presence of oral Candida albicans in patients with oronasal communications and to evaluate the effectiveness of a topical antifungal treatment, cytological smears obtained from the buccal and palatal mucosa of 10 adult patients, and from the nasal acrylic surface of their obturator prostheses were examined. A therapeutic protocol comprising the use of oral nystatin (Mycostatin) and prosthesis disinfection with sodium hypochlorite was prescribed for all patients. Seven patients were positive for C. albicans in the mucosa, with 1 negative result for the prosthetic surface in this group of patients. Post-treatment evaluation revealed the absence of C. albicans on prosthesis surface and on the oral mucosa of all patients. The severity of the candidal infection was significantly higher in the palatal mucosa than in the buccal mucosa, but similar in the palatal mucosa and prosthesis surface, indicating that the mucosa underlying the prosthesis is more susceptible to infection. The therapeutic protocol was effective in all cases, which emphasizes the need for denture disinfection in order to avoid reinfection of the mucosa.

Prospective aetiological study of diaper dermatitis in the elderly

The different causes of diaper dermatitis (DD) in the elderly are not well known and the treatment is often empirical. To determine the causes of DD in the elderly and to evaluate the efficacy of antifungal treatments in this indication. Consecutive patients presenting with DD were included. Clinical evaluation, skin swabs for bacterial and mycological cultures, patch testing and skin biopsy were performed at inclusion. This was followed by 1 month of topical antifungal cream and, if needed, by oral fluconazole for the second month. Forty-six patients were included (mean age 85 years). Causes of DD were established for 38 patients: 24 had candidiasis (63%), six irritant dermatitis (16%), four eczema (11%) and four psoriasis (11%). After 2 months of treatment, 27 of 37 (73%) patients were cured and five of 37 were improved. Mycoses and irritant dermatitis are the main causes of DD in the elderly, and emollient skin care and topical antifungal treatment can be considered a first-line therapy for this indication.