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`Journal of the
`American Academy of
`DERMATOLOGY
`
`Copyright © I996 by the American Academy of Dermatology, Inc.
`
`L D,,,,,,,,,, MD
`ssociate Editor
`bilice H. Thiers, MD
`5,it0rial Office
`Departnient of Dermatology
`’-‘tlical University of South Carolina
`171 Ashley Ave.
`{“i:u‘leston, SC 294252215
`303-792-9155
`
`I
`
`‘=-gsistant Editors
`Elizabeth A. Abel, MD
`7t5""""’”"” View’ Cahfomlfl
`Jeffrey D. Bernhard, MD
`‘zbrcester, Massachusetts
`Michael E. Bigby, MD
`'..loston, Massachusetts
`Jeffrey P. Callen, MD
`-Ioitisville, Kentucky
`Clay J. Cockerell, MD
`’lullas, Texas
`Mark V. Dahl, MD
`,m.,mmp0h.s_ Mmnema
`Madeleine Duvjc’ MD
`Houston, Texas
`Mary Maloney, MD
`51m"'€."v P€"”53’1V“"l“
`Bria“ Ni°k°1°ffv
`Ann Arbor, Michigan
`Amy S. Pallet, MD
`C/zicago, Illinois
`Neal s. Penneys, MD
`5’- U’”i5v M'7“0“’i
`Smart J. Salasche, MD
`ll1(‘.YOIl, Arizona
`Rnbm A_ Schwartz, MD
`Newark, New Jersey
`g1iZ.,,beth Sherelm MD
`Wilistrm-Salem, North Carolina
`ilvln R. Solomon. MD
`Atlanta, Georgia
`Vennetii J. Tomecki, MD
`Cleveland, Ohio
`nmlnding Editor
`J. Graham Smith, Jr., MD
`Mobile, Alabama
`Vol. 35, N0. 4, October 1996, the Journal of the Ameri—
`.
`tri Academy of Dermatology (ISSN 0190-9622) is pub-
`lished monthly (six issues per volume, two volumes per
`_m by MOsby_Yw Book Inc” 11830 Wmlme mdw
`mu: D12, St. Louis. Mo 63146331s.i=en'oc11caIs postage
`; aid at St. Louis, Missouri. and additional mailing offices.
`Postmaster: Send address changes to Journal of the
`1 niericzin Academy of Dermatology, Mosby—Ycar Book,
`lJll.‘., 11830 Westline lridustrial Dr., SL Louis, MO 63146-
`7118. Annual subscription rates: $144.00 for individuals,
`$248.00 for institutions. Printed in the U.S.A. Copyright
`1996 b ‘the AmcricanAcadc1ii of Dcimatolog , nc.,
`1ao.Boxy4o14,sctmumburg,iLl:016s4o14.
`y I
`
`CONTENTS October 1996
`
`CONTINUING MEDICAL EDUCATION
`
`Herpes Simplex: Evolving concepts
`,
`-
`-
`,
`Frederick A. Pereira, MD New York, New York
`
`Answers to CME examination (Identification
`No. 896-109), October issue of the Journal of
`the American Academy of Dermatology
`
`_
`_
`CME examination
`
`CLINICAL AND LABORATORY STUDIES
`
`Localized involutional lipoatrophy: A
`clinicopathologic study of 16 patients
`PEllI'lCl(
`Dahl, MD,
`Zalla, MD, and
`R. K. Winkelmann, MD, PhD
`Rochester, Minnesota, and
`Scottsdale, Arizona
`
`_
`_
`_
`Neurocutaneous melanosis: Clinical features of
`large congenital melanocytic nevi in patients
`with manifest central nervous system
`melanosis
`.
`.
`Maria DeDaV1d, MD, Seth J. Orlow, MD, PhD,
`Nathalie Provost! MD?
`Ashfaq A. Marghoob, MD, Babar K. Rao, MD,
`Qasirn Wasti, MD, Carol L. Huang, BA,
`Alfred W. Kopf, MD, and Robert S. Bart, MD
`New York and Stony Brook, New York
`
`_
`A U.S. epidemiologic survey of superficial
`fungal diseases
`Maggi E- Kemnas MT(ASCP)a and
`B0T1i E. El6WSl<i, MD Cleveland, Ohio
`
`.
`.
`.
`.
`.
`.
`Utilization of outpatient care for psoriasis
`R0l3€1"t 5- Sl61T1, MD BOSIUVI, MdSSdCl1MS€t1S
`
`V
`B A MOSby
`
`Continued on page 7A
`5A
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`

`
`Contents
`
`continued
`
`Synergistic topical photoprotection by a combination of the iron chelator
`2-furildioxime and sunscreen
`Donald L. Bissett, PhD, and James F. McBride Cincinnati, Ohio
`
`Standard and high resolution magnetic resonance imaging of glomus
`tumors of toes and fingertips
`Jean—Luc Drape, MD, llana Idy—Peretti, MD, PhD, Sophie Goettmann, MD,
`Henri Guérin—SurVille, MD, and Jacques Bittoun, MD, PhD Paris, France
`
`Value of urinary N-methylhistamine measurements in childhood
`mastocytosis
`Dirk Van Gysel, MD, Arnold P. Oranje, MD, PhD, Ida Veimeiden, MD,
`Jacqueline de Lijster dc Raadt, Paul G. H. Mulder, PhD, and Albert W. van
`Toorenenbergen, PhD Aalst, Belgium, and Rotterdam, The Netherlands
`
`A multirater validation study to assess the reliability of acne lesion
`counting
`Anne W. Lucky, MD, Beth L. Barber, PhD, Cynthia J. Ginnan, DrPH,
`Jody Williams, RN, BSN, Joan Rattemian, RN, and
`Joanne Waldstreicher, MD Cincinnati, Ohio, and Rahway, New Jersey
`
`Acute lipodermatosclerosis is associated with venous insufficiency
`Adam S. Greenberg, MD, Anthony Hasan, MD, Berta M. Montalvo, MD,
`Anne Falabella, MD, and Vincent Falanga, MD Miami, Florida
`
`THERAPY
`
`Botulinum A exotoxin for glabellar folds: A double-blind,
`placebo-controlled study with an electromyographic injection technique
`Nicholas J. Lowe, MD, Anne Maxwell, MD, and Heather Harper, BS
`Santa Monica, California, and London, United Kingdom
`
`Photopheresis therapy for cutaneous T-cell lymphoma
`Madeleine Duvic, MD, Jeane P. Hester, MD, and Noreen A. Lemak, MD
`Houston, Texas
`
`DERMATOLOGIC SURGERY
`
`Nasal reconstruction with the cheek island pedicle flap
`Scott W. Fosko, MD, and Leonard M. Dzubow, MD St. Louis, Missouri, and
`Philadelphia, Pennsylvania
`
`Smteincnts and opinions expressed in the aiticlcs and communications herein are those of the authoiis) and not necessarily those of the Editor(s), publisher, or Academy, and the
`i.'ull[()l'(S), publisher, and Academy disclaim any responsibility or liability for such material. Neither the Editor(s), publisher, nor the Academy guarantees, warrants, or endorses
`any product or service advertised in this publication, nor do they guarantee any claim made by the manufacturer of such product or service.
`
`Journal of the American Academy of Dermatology
`
`October 1996
`
`7A
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`Continued on page 9A
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`

`
`Contents
`
`continued
`
`CORRECTIONS
`
`Correction to Webster GF, Knobler RL, Lublin FD, Kramer EM,
`Hochman LR (J Am Acad Dermatol 1996;34:365-7)
`
`Correction to Duvic M, Lemak NA, Redman JR, Eifel PJ, Tucker SL,
`Cabanillas FF, Kurzrock R (J Am Acad Dermatol 1996;34:1022-9)
`
`Correction to Desgarennes MCP, Godoy MR, Palencia AB (J Am Acad
`Dermatol 1996;35:114-6)
`
`CLINICAL REVIEWS
`
`A clinicopathologic approach to granulomatous dermatoses
`Laura Osofsky Rabinowitz, MD, and M. Tafif Zaim, MD Cleveland, Ohio
`
`Genital herpes: An integrated approach to management
`Marcus A. Conant, MD, Timothy G. Berger, MD, Thomas J. Coates, PhD,
`David J. Longo, PhD, June K. Robinson, MD, and Lynn A. Drake, MD
`San Francisco, California; Danville, Pennsylvania; Chicago, Illinois; and
`Boston, Massachusetts
`
`SPECIAL REPORT
`
`An evaluation of the accuracy of residency applicants’ curricula vitae:
`Are the claims of publications erroneous?
`Alan S. Boyd, MD, Matt Hook, MS, and Lloyd E. King, Jr., MD, PhD
`Nashville, Tennessee
`
`ACADEMY GUIDELINES
`
`Guidelines of care for scleroderma and sclerodermoid disorders
`
`AAD Guidelines/Outcomes Committee, Lynn A. Drake, chairman
`
`Guidelines of care for the use of topical glucocorticosteroids
`AAD Guidelines/Outcomes Committee, Lynn A. Drake, chairman
`
`Guidelines of care for vitiligo
`AAD Guidelines/Outcomes Committee, Lynn A. Drake, chairman
`
`PEARLS OF WISDOM
`
`Clinical Pearl: Discoid lupus erythematosus——Treatment with occlusive
`compression
`CPT Kurt L. Maggio, MC, USA, COL Michael T. Singer, DC, USA, and
`COL William D. James, MC, USA Washington, D. C.
`
`Iotaderma #33
`
`Jeffrey D. Bernhard, MD Worcester, Massachusetts
`
`Journal of the American Academy of Dermatology
`
`Continued on page ]]A
`
`October 1996
`
`9A
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`
`(‘nntents Continued
`_w.
`
`BRIEF COMMUNICATIONS
`
`Sweet’s syndrome induced by granulocyte colony-stimulating factor in a
`woman with congenital neutropenia
`Marie Aleth Richard, MD, Jean Jacques Grob, MD,
`Renaud Laurans, Sylvie Hesse, MD, Philipe Brunet, MD,
`Anne Marie Stoppa, MD, Jean Jacques Bonerandi, MD, Yvon Berland, MD,
`and Dominique Maraninchi, MD Marseille, France
`
`Erythema of the proximal nailfold in HIV-infected patients
`Peter H. Itin, MD, Luzius Gilli, MD, Reto Niiesch, MD,
`Salome Courvoisier, MD, Manuel Battegay, MD, Theo Rufli, MD, and
`Paul Gasser, MD Basel, Switzerland
`
`Circle hairs are not rolled hairs
`Jeffrey B. Smith, MD, and Daniel J. Hogan, MD Tampa and
`Bay Pines, Florida
`
`Is mycosis fungoides exacerbated by fluoxetine?
`Maarten H. Vermeer, MD, and Rein Willemze, MD
`Amsterdam, The Netherlands
`
`Treatment of tinea capitis with itraconazole
`Donald L. Greer, PhD New Orleans, Louisiana
`
`Fixed food eruption
`CDR John M. Kelso, MC, USN San Diego, California
`
`Sjiigren’s syndrome associated with thymoma
`Yoshinari Matsumoto, MD, Satoko Hirai, MD, Masaru Ohashi, MD, and
`Munehisa Imaizumj, MD Nagoya, Japan
`
`Intracranial osteolytic meningioma affecting the scalp
`Maria E. lglcsias, MD, F. Javier Vzi7quez—Doval, I\/[D, Miguel A. ldoate, MD,
`Vicente Vanaclocha, MD, Fernando ldoate, MD, and Emilio Quintanilla, MD
`Pamplona, Spain
`
`Retrospective review of the use of azathioprine in severe atopic dermatitis
`John T. Lear, MRCP(UK), John S. C. English, MRCP(UK), Peter Jones, PhD,
`and Andrew G. Smith, FRCP(UK) Stoke on Trent, Staflordshire,
`United Kingdom
`
`Propolis allergy in an HIV-positive patient
`Stefania Bellegrandi, MD, Gianpiero D’Offizi, MD, Ignacio J. Ansotegui, MD,
`PhD, Rosetta Ferrara, MD, Enrico Scala, MD, and Roberto Paganelli, MD
`Rome, Italy
`
`Two patients with confluent and reticulated papillomatosis: Response to
`oral isotretinoin and 10% lactic acid lotion
`Barry A. Solomon, MD, and Teresita A. Laude, MD Brooklyn, New York
`
`Nonpigmented fixed drug eruption from pseudoephedrine
`Kristiina Alanko, MD, PhD, Lasse Kanerva, MD, PhD,
`Berit Mohell—Talo1ahti, MD, Riitta Jolanki, DTech, and
`Tuula Estlander, MD, PhD Helsinki, Finland
`
`Journal of the American Academy of Dermatology
`
`Continued on page 13A
`
`October 1996
`
`11A
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`
`Contents Contiriued
`
`_ C
`
`ORRESPONDENCE
`
`Every day is Melanoma Monday
`Stephen E. Chiarello, MD P011 Clzarlotfe, Florida
`
`Dermatoheliosis?
`Robert S. Bart, MD New York, New York
`
`More on cutaneous reactions to recombinant cytokine therapy
`Frédérique—Anne Le Gal, MD, Carle Paul, MD, Philippe Chemaly, MD, and
`Louis Dubertret, MD Paris, France
`
`Reply
`Anthony A. Gaspati, MD Rochester, New York
`
`Cold panniculitis in a neonate
`D. Ben-Amitai, MD, and A. Metzker, MD Peta/1 Tiqvah, Israel
`
`Reply
`Adelaide A. Hebert, MD Houston, Texas
`
`Dermabrasion and epithelial sheet grafting
`Seung—Kyung Hann, MD, and Yoon—Kee Park, MD Seoul, Korea
`
`Reply
`Arthur M. Kahn, MD, and Myles J. Cohen, MD Los Angeles, California
`
`READER SERVICES
`
`Information for authors
`
`Information for readers
`
`Dermatology calendar
`
`Dermatology opportunities
`
`Instructions for Category I CME credit
`
`CME examination answer sheet
`
`lndex to advertisers
`
`20A, 21A, and 22A
`
`25A
`
`65A
`
`71A
`
`26A
`
`31A
`
`76A
`
`101111131 of the American Academy of Dermatology
`
`October 1996
`
`13A
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`This material may be protected by Copyright law (Title 17 U.S. Code)
`
`A U.S. epiderniologic survey of superficial
`
`fungal diseases
`
`Maggi E. Kemna, MT (ASCP), and Boni E. Elewski, MD Cleveland, Ohio
`
`Background: Large—scale studies performed outside the United States have demonstrated that
`most cases of onychomycosis and tinea pedis are caused by dermatophytes, primarily Tri-
`chophyton mbmm. However, other studies have suggested that yeasts and nondermatophytic
`molds may play a role, particularly in onychomycosis.
`Objective: This study was undertaken to determine the epidemiology of superficial fungal
`infections in a U.S. population.
`Methods: Fungal cultures were performed on patients with clinically suspected tinea cruris,
`tinea corporis, tinea capitis, tinea pedis, and onychomycosis.
`Results: Derrnatophytes were the most commonly isolated fungi in each type of superficial
`fungal disease studied. T. rubrum was the most commonly isolated demiatophyte species, al-
`though Trichop/iyton tonsurans was more common in tinea capitis and equally common ir1
`tinea corporis/tinea cruris. In tinea pedis and onychomycosis, dermatophytes appeared in ap-
`proximately 95% and 82% of isolates, respectively. Candida albicans and nondennatophyte
`molds played only a minor role in onychomycosis; C. albicans was isolated in 7% of nail
`cultures and nonderrnatophytic molds were isolated in 11%.
`Conclusion: These results are in general agreement with other major epidemiologic studies
`performed outside the United States. Dermatophytc fungi cause most superficial fungal in-
`fections.
`
`(J Am Acad Dermatol l996;35:539-42.)
`
`Dcrmatophytes cause most superficial fungal in-
`fections, but some yeasts and nonderrnatophytic
`molds are also sometimes involved.‘ Onychomyco—
`sis and tinea pedis are two of the most common su-
`perfimlal fungal diseases. Recent discussion has fo-
`cused on the importance of nondermatophytes in
`these diseases, particularly in onychomycosis.2'4
`How‘:-ver, data from studies in Canada5 and the
`United Kingdom6 indicate that nondermatophytes
`play a small role in these infections.
`Tlizz: purpose of this study was to detennine the
`epidemiology of superficial fungal diseases includ-
`ing onychomycosis, tinea pedis, tinea cruris, tinea
`Corporis, and tinea capitis in a U.S. population.
`
`From The Center for Medical Mycology and the Department of Der-
`Inatoi.;gy, University Hospitals of Cleveland.
`Accepted for publication March 19, 1996.
`Repfinl requests: Boni E. Elewski, MD, Center for Medical Mycology,
`D€l??’~*’fment of Dennatology, University Hospitals of Cleveland,
`Cleveland, OH 44106.
`
`C0PyI1};.~.; © 1996 by the American Academy of Dermatology, Inc.
`0190-9622/96 $5.00 + 0
`16/1/73485
`
`METHODS
`
`A total of 1222 specimens (no more than one from each
`patient) were analyzed between January and December
`1994. These specimens of nail, skin, and hair came from
`clinics, private physicians, and clinical trial programs
`(initial isolate). In most instances, data were not available
`on patient demographics. Sixteen states were represented:
`Alabama, California, Colorado, Georgia, Illinois, Louisi-
`ana, Maryland, Michigan, Minnesota, New Jersey, North
`Carolina, Ohio, Oregon, Rhode Island, Virginia, and
`Wisconsin.
`
`Specimens were submitted to the laboratory in (1) Sa-
`bouraud’s dextrose agar with 0.04% cyclohexirnide, (2)
`dermatophyte test medium (DTM), or (3) a Derma—Pak
`(Microbiological Supply Co., Toddington, Bedfordshire,
`U.K.). Each specimen that arrived in a Derma—Pak was
`examined by Calcofluor (Sigma Chemical Co., St. Louis,
`M0.) in 5% potassium hydroxide microscopy and was
`inoculated on Sabouraud’s dextrose agar with and with-
`out ().04% cycloheximide.
`All cultures were incubated at 30° C and checked twice
`
`weekly; a minimum of 4 to 6 weeks was allotted to con-
`firm any negative cultures.
`lnitial cultures that grew fungi suspected to be Trich0-
`phyton were inoculated on Trichophyton agars #1 and #4
`
`539
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`
`540 Kemna and Elewski
`
`Journal of the American Academy of Dermatolt:-gy
`October 1996
`
`Table 1. Specimens with fungal growth
`
`Suspected
`infection
`
`Specimens
`Total
`specimens with growth
`
`Onychomycosis
`Tinea pedis
`Tinea cruris/tinea corporis
`Tinea capitis
`Total
`
`50.3
`370
`736
`36.5
`38
`129
`29.5
`69
`189
`168 E 50.0
`W 561
`45.9
`
`slants and on Christianson’s urea agar slants. Baby mixed
`cereal agar7 plates were used to induce conidia. These
`subcultures were examined after 1 week of incubation at
`
`30° C. If test results were inconclusive, the hair perfora-
`tion test was performed or rice grains were added to
`identify other derrnatophyte species. Nondermatophytic
`molds were often identified by microscopic growth on
`potato dextrose agar and other media and by manipula-
`tion of the temperature and observation of their growth.
`Yeasts were grown in corn meal with Tween 80 agar, by
`means of the Dalmau technique. Growth on media con-
`taining cycloheximide and the presence of fermentation
`in carbohydrates (dextrose, maltose, sucrose, lactose, cel-
`lobiose, and trehalose) helped to identify yeasts. Occa-
`sionally, Christianson’s urea, nitrate assimilation, or car-
`bohydrate assimilation in the API 20C test (bioMerieux
`Vitek, Inc., Hazelwood, Mo.) was used to confirm iden-
`tification.
`
`Slide cultures were performed when necessary. Molds
`growing in culture were routinely blotted with cellophane
`tape, and the material picked up by the tape was applied
`to a slide with Calcofluor in 5% potassium hydroxide.
`Derrnatophyte conidia are produced more rapidly on me-
`dia with less dextrose; therefore dermatophyte—like iso-
`lates were planted on cereal agar and incubation was
`continued for 1 week. The development of additional
`structures during that week indicated a dermatophyte. For
`nonderrnatophytic molds, slide cultures were prepared
`with potato dextrose agar, which encourages growth of
`conidia. When no conidia were seen, tap water, corn meal,
`Czapek solution agars (Difco Co., Detroit, Mich.), and/or
`cereal agars were used for these isolates.
`All totals were tallied with the Paradox (Borland Inter-
`national, Inc., Scotts Valley, Calif.) program.
`
`RESULTS
`
`Of the 1222 specimens analyzed, 561 (45.9%)
`grew at least one fungal species (Table I). The
`pathogen recovery rate varied by disease, from
`50.3% in clinically suspected onychomycosis to
`29.5 % in suspected tinea cruris/tinea corporis. Of the
`specimens that grew fungus, derrnatophytes were
`predominant in each disease (Table 11). Overall, T.
`
`rubrum was the most common derrnatophyte. It was
`present most frequently in onychomycosis and tinea
`pedis, accounting for 76.2% and 78.9% of isolatis,
`respectively. In tinea capitis, T. ronsurans was pre-
`dominant, accounting for 88.1% of all isolates and
`90.2% of derrnatophyte isolates. In tinea cruris/tinea
`corporis, the combined frequency of isolation of T,
`rubmm and T. tonsurans was 40.6%.
`
`C. albicans was isolated in each type of infection
`but was not considered clinically relevant except in
`patients with tinea cruris/tinea corporis.
`
`DISCUSSION
`
`This U.S. study confirms that the vast majority of
`superficial fungal infections are produced by der-
`matophytes. Dermatophytes caused 94.7% of cases
`of tinea pedis and were found in 81.9% of cases of
`onychomycosis. The epidemiology of onychomy-
`cosis and tinea pedis in the United States is similar
`to that reported in Canada5 (90.7% and 97.1% der-
`matophytes, respectively) and in the United King-
`dom6 (80.6% derrnatophytes in onychomycosis);
`dermatophytes are by far the most common fuiigi.
`In the U.K. study, Clayton6 found only 1% Can-
`dida species in the isolates of toenails but 58% in
`those of fingernails; however, the study included
`chronic paronychia as well as onychomycosis and
`had an unusually low rate of recovery (73% of fin-
`gernail isolates failed to grow). Of total samples in
`Clayton’s study, only 16% grew Candida.
`Yeasts have not been shown to be keratinolytic,
`and no mechanism for their primary invasion into
`nails has clearly been established. Yeasts may (Ol-
`onize glabrous skin, hair, and nails and may become
`pathogenic only in association with preexisting
`infection, trauma, loss of epidermal barrier function,
`or immunodeficiency.6=8’9 For example, Candida
`can be recovered from the mouths of 30% of healthy
`adults,” but acute pseudomembranous candidiasis is
`rarely encountered in healthy adults and, wierl
`present, may be a harbinger of diabetes mellitus,
`AIDS, or other primary or secondary immunodefi-
`ciency. To assess the clinical significance of the re—
`covery of Candida, clinical and pathologic correla-
`tion is important. We isolated Candida from 48% of
`tinea cruris/tinea corporis cultures. Without clinical
`correlation the significance is impossible to dcrf:r—
`mine. Likewise, we cultured C. albicans in 2.3% Of
`scalp isolates, but because C. albicans does not cause
`
`tinea capitis, we believe that all of the pathog”I15
`were dennatophytes. In tinea pedis, 5.3% of isolates
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`
`Journal of the American Academy of Dermatology
`Volume 35, Number 4
`
`Kemna and Elewski 541
`
`Table ‘ll. Fungi isolated
`/_’_,__._
`
`Onychtlmycosis
`Dennatophytes
`T. rubrum
`T. mentagrophytes
`T. tonsurans
`
`Epidermophyton floccosum
`Micmsporum gypseum
`Subtotal
`( .~.7/bicans
`Nonderrnatophyte n1olds*
`Scapulariopsis brevicaulis
`Acremonium species
`.-"iS‘])eI‘gillLtS versicolor
`Fusarium solani
`
`Aspergillus terreus
`spergillus flavus
`Scyraliditzm dimidiatum
`Subtotal
`Total
`
`Tinea capitis
`l}a?;.z‘n1atophytes
`T. torzsuram
`T. rubrum
`M. cam":
`
`T. menzagrophytes
`.32’. gypseum
`Subtotal
`C. albicans
`Total
`
`Tinea cruris/tinea corpofis
`
`Deimatophytes
`T. rubmm
`T. Ioitsurans
`M. canis
`
`T. mentagrophytes
`I". vermcosum
`Subtotal
`C. albicans
`Total
`
`Tinea pedis
`Dermatophytes
`I: mbmm
`
`T. mentagrophytes
`Subtotal
`
`C albicans
`Total
`
`No. of isolates
`
`% Total growth
`
`% Dermatophytes
`
`282
`12
`7
`
`l
`_l
`
`78.9
`
`36
`
`2
`R
`
`94.7
`
`100.0
`
`We cannot determine whether these are pathogens because we have no potassium hydroxide results.
`
`grew Candida, but we cannot tell whether they were
`Pathogmic because we lack the clinical data.
`Nonrlerrnatophytic molds may be recovered as
`“C0I1taminants” from glabrous skin, hair, and nails.
`Stfingeni criteria must be met before a yeast or non—
`
`dermatophytic mold grown from a specimen is ac-
`cepted as a causative agent. English” has proposed
`that a nondermatophytic mold must grow from at
`least 5 of 20 inocula, with no dermatophyte growth,
`to be considered clinically significant. Summerbell,
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`
`542 Kemna and Elewski
`
`Journal of the American Academy of Dermatology
`October 5996
`
`Kane, and Kraj den5 added the presence in direct mi-
`croscopy of atypical hyphae and/or conidia to the list
`of criteria.
`
`The relations between derinatophytes and non-
`dermatophytes in onychomycosis may be similar to
`the situation in interdigital tinea pedis in which der-
`matophytosis simplex can progress to der1natophy—
`tosis complex.l2=13 According to Leyden, dermato-
`phyte infection of the toe—webs may create a hospi-
`table environment for bacteria that normally would
`not colonize the area. These bacteria can overgrow
`and mask the underlying derrnatophyte infection.
`Similarly, dennatophyte infection of the nail may
`create conditions favorable to both bacteria and
`
`saprophytic molds, which on culture often overgrow
`dermatophytes, impeding their isolation. Therefore a
`saprophytic mold growing from a patient with a
`clinical impression of onychomycosis may not be
`the original pathogen, but may represent valid
`growth. Laboratory isolation of the dermatophyte
`may have been impeded by the saprophyte in the
`same way isolation of dermatophytes can be im-
`peded by bacteria in the derrnatophytosis complex
`syndrome.12=13 This phenomenon in the nail could
`be called “onychomycosis complex.” Fungal cul-
`ture results need to be interpreted closely in correla-
`tion with the clinical situation. The clinician should
`
`when the potassium hydroxide
`be alert for
`reveals septate hyphae and only saprophytes were
`recovered in the laboratory.
`The majority of cultures received in our study
`were already planted on media plates; therefore no
`direct microscopy was done; this hampered analysis
`of the significance of the recovered nonderrnato—
`phytic molds (Table IT).
`The most likely reason that more than half the
`cultures failed to grow is that there was no fun-
`gus. Fungi cause only 50% of nail disorders,” and
`other skin conditions can mimic cutaneous fungal
`infections. Other factors that may account for the
`
`low recovery rate are antimycotic use by the pa.
`tient, variable methods of culture collection, and
`
`bacterial or saprophytic overgrowth. In Clayton’s
`study6 of onychomycosis, 66% of samples from
`toenails and 73% of samples from fingernails had
`no growth, which is somewhat less than our recov-
`ery rate.
`
`REFEREN CES
`
`1. Rippon JW. Cutaneous infections: dermatophytosis. and
`derrnatomycosis. In: Medical mycology: The pathogenic
`fungi and the pathogenic actinomycetes. 3rd ed. Philadel-
`phia: WB Saunders, 19882169-275.
`. Rosen T. Emerging role of yeasts and nondennatophytic
`molds in fungal nail infections.
`Int J Dermatol E994;
`33:292-9.
`. Ramani R, Srinivas CR, Ramani A, et al. Molds in
`onychomycosis. lntJ Dermatol l993;32:877-8.
`. Willemsen M. Changing patterns in superficial infex :ion-
`szfocus on onychomycosis. J Eur Acad Dermatol 1993;
`2(suppl l):S6—Sl 1.
`. Summerbell RC, Kane J, Krajden S. Onychomycosis, tinea
`pedis and tinea manuum caused by non—derrnatophync fil-
`amentous fungi. Mycoses l989;32:609-l9.
`. Clayton YM. Clinical and mycological diagnostic aspects
`of onychomycoses and derrnatomycoses. Clin Exp Der-
`matol l992;l7(suppl l):37-40.
`. Padhye AA, Sekhon AS, Carmichael .lW. Ascocan“ pro-
`duction by nannizzia and aithroderma on keratinous and
`non-keratinous media. Sabouraudia l973;ll:lO9—l4’
`. Elewski BE. Cutaneous fungal infections. New York:
`lgaku—Shoin, 1992.
`In:
`. Rippon JW. Candidiasis and the pathogenic yeasts.
`Rippon JW, Wonsiewicz M. editors. Medical mycclogy:
`the pathogenic fungi and the pathogenic actinomycetes. 3rd
`ed. Philadelphia: WB Saunders, l988:532-81.
`. Cohen R, Ross FJ, Delgado E, et al. Fungal flora of the
`normal human small and large intestine. N Engl J Med
`1969;280:638-41.
`. English MP. Nails and fungi. Br J Dermatol 1976;94:697-
`701.
`
`. Leyden JJ, Kligman AM. I nterdigital athlete’ s foot: the in—
`teraction of dermatophytes and resident bacteria. Arch
`Dermatol l 978;l l4:l466—72.
`. Leyden JJ. Progression of interdigital infections fror:~ sirn-
`plex to complex. J Am Acad Dermatol 1993 ;28:S7—ll.
`. Cohen JL, Scher RK, Pappert AS. The nail and fung as in-
`fections. In: Elewski BE, editor. Cutaneous fungal infeC'
`tions. New York: Igaku—Shoin, l992:l06-23.
`
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