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`

`Journal of the
`American Academy of
`DERMATOLOGY
`
`Copyright © 1 996 by the American Academy of Dermatology, Inc.
`
`December 1996
`
`CONTINUING MEDICAL EDUCATION
`
`Drug photosensitivity, idiopathic
`photodermatoses, and sunscreens
`Ernesto Gonzalez, MD, and
`Salvador Gonzalez, MD
`Boston, Massachusetts
`
`CME examination
`
`Answers to CME examination (Identification
`No. 896-111), November 1996 issue of the
`Journal of the American Academy of
`Dermatology
`
`CLINICAL AND LABORATORY STUDIES
`
`Damage to hair follicles by normal-mode ruby
`laser pulses
`Melanie C. Grossman, MD,
`Christine Dierickx, MD,
`William Farinelli, BS,
`Thomas Flotte, MD,
`and R. Rox Anderson, MD
`Boston, Massachusetts
`
`Psychologic effects of vitiligo: A critical
`incident analysis
`Gerry Kent, PhD, and
`Mohammed Al’Abadie, MD, PhD
`S/zeflield and Wolverhampton, United Kingdom
`
`NA Mosby
`
`Continued on page 7A
`
`Editor
`R.chard L. Dobson, MD
`Associate Editor
`Bruce H. Thiers, MD
`Editorial Office
`Department of Dermatology
`Medical University of South Carolina
`l7J Ashley Ave.
`1
`Cltarleston, SC 29425-2215
`803-792-9] 55
`
`A* sistant Editors
`Elizabeth A. Abel, MD
`‘Von/rtairz View, Cali omia
`Jeffrey D. Bernhard, MD
`Worcester, Massachusetts
`Michael E. Bigby, MD
`Pasta/1, Massachusetts
`Jeffrey P. Callen, MD
`I *ruisw'lIe, Kentuc/<_v
`Clay J. Cockerell, MD
`Prrllas, Texas
`Mark V. Dahl, MD
`:'.~’nneapolis, Minnesota
`Madeleine Duvic, MD
`Hiztston, Texas
`Mary Maloney, MD
`I ‘xrshey, Pennsylvania
`Brian Nickoloff, MD
`Ann Arbor, Michigan
`Amy S. Puller, MD
`(lucago, Illinois
`Neal S. Penneys, MD
`5. Louis, Missouri
`Stuart J. Salasche, MD
`'/cgcson, Arizona
`Robert A. Schwartz, MD
`/Vswarlc, New Jersey
`Elizabeth Sherertz, MD
`V; Jnston—SaIen1, North Carolina
`Alvin R. Solomon, MD
`Aukrnta, Georgia
`Kenneth J. Tomecki, MD
`C reveland. Ohio
`
`Founding Editor
`J. Graham Smith, Jr., MD
`Mvhile, Alabama
`Vol. 35. No. 6. December 1996, the Journal of the Amer-
`ican 7 saclemy of Dermatology (ISSN 01909622) is pub-
`lished monthly (six issues per volume, two volumes per
`Year} 9}’ Mosby—Year Book, Jnc., 11830 Wcstline Indus-
`trial Dr., St. Louis, MO 63146-3318. Periodicals postage
`Paid :1 St. Louis, Missouri, and additional mailing offices.
`Postmaster: Send address changes to Journal of the
`American Academy ofDermatology, Mosby—Year Book,
`Inc, I I830 Weslline Industrial Dr., St. Louis, MO 63146-
`3318 Annual subscription rates: $144.00 for individuals,
`$248.00 for institutions. Printed in the USA. Copyright
`© 1996 by the American Academy of Dermatology, Inc.,
`PO. Box 4014, Schaumburg. IL 601684014.
`
`5A
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`

`tfontents Continued
`
`.__j___.
`
`Chronic telogen eflluvium: Increased scalp hair shedding in
`middle-aged women
`David A. Whiting, MD, FRCP(Edinb) Dallas, Texas
`
`Increased proportion of aggressive-growth basal cell carcinoma in the
`Veterans Affairs population of Palo Alto, California
`David A. Wrone, Susan M. Swetter, MD, Barbara M. Egbert, MD,
`Bruce R. Smoller, MD, and Paul A. Khavaii, MD, PhD Palo Alto
`and Stanford, Cali omia
`
`Sunny Days, Healthy Ways: Evaluation of a skin cancer prevention
`curriculum for elementary school—aged children
`David B. Buller, PhD, Mary K. Buller, MA, Barbara Beach, PhD, and
`Gregory Eitl, MD Tucson and Yuma, Arizona
`
`Localized scleroderma in breast cancer patients treated with supervoltage
`external beam radiation: Radiation port scleroderma
`Daniel A. Davis, MD, Philip R. Cohen, MD, Marcia D. McNeese, MD, and
`Madeleine Duvic, MD Galveston and Houston, Texas
`
`Oral hairy leukoplakia in 71 HIV-seropositive patients: Clinical
`symptoms, relation to immunologic status, and prognostic significance
`Ralf Husak, MD, Claus Garbe, MD, and Constantin E. Orfanos, MD
`Berlin, Germany
`
`THERAPY
`
`Long-term follow-up of patients with cutaneous T-cell lymphoma treated
`with extracorporeal photochemotherapy
`John A. Zic, MD, George P. Stiicklin, MD, PhD, John P. Greer, MD,
`Marsha C. Kinney, MD, Yu Shyr, PhD, David C. Wilson, MD, and
`Lloyd E. King, Jr., MD, PhD Nashville, Tennessee, and
`Lynchburg, Virginia
`
`Treatment of cutaneous T-cell lymphoma with extracorporeal
`photopheresis monotherapy and in combination with recombinant
`interferon alfa: A 10-year experience at a single institution
`Scott L. Gottlieb, MD, Jonathan T. Wolfe, MD, Floyd E. Fox, PhD,
`Barbara J. DeNardo, RN, William H. Macey, RN, Patricia G. Bromley, RN,
`Smart R. Lessin, MD, and Alain H. Rook, MD Philadelphia, Pennsylvania
`
`Treatment of Candida nail infection with terbinafine
`Rina Segal, MD, Aharon Kritzman, MD, Lia Cividalli, PhD,
`Zmira Samra, PhD, and Michael David, MD Peiah Tiqva, Israel
`
`...._
`
`Continued on page 9A
`
`Sflitenicnts and opinions expressed in the articles and coinmunications herein are those of the author(s) and not necessarily those of Ihe Editor(s), publisher, or Academy, and the
`Edltor ~:), publisher, and Academy disclaim any responsibility or liability for such material. Neither the Editor(s), publisher. nor the Academy guarantees, warrants, or endorses
`any Pi'()dL1C[ or service advertised in this publication, nor do they guarantee any claim made by the manufacturer of such product or service.
`7A
`Journal of the American Academy of Dermatology
`December 1996
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`

`continued
`Contents
`.,
`
`DERNIATOPATHOLOGY
`
`The starburst giant cell is useful for distinguishing lentigo maligna from
`photodamaged skin
`Lisa M. Cohen, MD Boston, Massachusetts
`
`CLINICAL REVIEW
`
`Rediscovering thalidomide: A review of its mechanism of action, side
`effects, and potential uses
`Stephanie Tseng, BA, Grace Pak, MD, Kenneth Washenilg MD, PhD,
`Miriam Keltz Pomeranz, MD, and Jerome L. Shupack, MD
`New York, New York
`
`PEARLS OF WISDOM
`
`Surgical Pearl: The trephine punch for diagnosing panniculitis
`Julide Tok, MD, Irving Abrahams, MD, Margaret A. Ravits, MD, and
`David N. Silvers, MD New York, New York
`
`Iotaderma # 35
`
`Jeffrey Bernhard, MD Worcester, Massachusetts‘
`
`BRIEF COMMUNICATIONS
`
`Reactive perforating collagenosis in Treacher Collins syndrome
`Yong—Kwang Tay, MD, William L. Weston, MD, and John L. Aeling, MD
`Denver, Colorado
`
`Septic microemboli in a Janeway lesion of bacterial endocarditis
`MAJ Richard P. Vinson, MC, USA, CPT Andrew Chung, MC, USA,
`LTC Dirk M. Elston, MC, USA, and MAJ Richard A. Keller, MC, USA
`Fort Sam Houston, Texas
`
`Metastatic Crohn’s disease of the face
`
`Wenchieh Chen, MD, Ulrike Blume-Peytavi, MD, Sergij Goerdt, MD, and
`Constantin E. Orfanos, MD Berlin, Germany
`
`Paraneoplastic urticaria in a patient with ovarian carcinoma
`Uwc Reinhold, MD, Thomas Bruske, MD, and Gunnar Schupp, MD
`Bonn, Germany
`
`Intestinal involvement in SWeet’s syndrome
`Olivier Fain, MD, Emmanuel Mathieu, MD, Nathalie Feton, MD,
`Mathilde Sibony, MD, Muriel Sitbon, MD, Frangoise Lejeune, MD, and
`Michel Thomas, PhD Bondy, France
`
`Cyclosporine in scleredema
`Georgia Mattheou-Vakali, MD, Demetris loannides, MD,
`Thomas Thomas, MD, E. Lazaridou, MD, P. Tsogas, MD, and A. Minas, MD
`Thessaloniki, Greece
`
`Journal of the American Academy of Dermatology
`
`Continued on page I IA
`December 1996
`9A
`
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`

`continued
`Contents
`,.
`
`Persistent cutaneous hypersensitivity reaction after a Hawaiian box
`jellyfish sting (Carybdea alata)
`Reid H. Tarnanaha, and Allan K. Izumi, MD Honolulu, Hawaii
`
`Carcinoma erysipelatoides resulting from genitourinary cancer
`LTC Dirk M. Elston, MC, USA, Ralph J. Tuthjll, MD, Joseph Pierson, MD,
`J. Daniel Marclen, MD, and Wihna F. Bergfeld, MD
`Cleveland, Ohio
`
`Sweet’s syndrome secondary to granulocyte colony-stimulating factor
`Paula Lyn Prevost—Blar1k, MD, and Tor Adam Shwayder, MD
`Detroit, Michigan
`
`Metastatic cutaneous carcinoid
`
`Gary A. McCracken, MD, Carl V. Washington, MD, and
`Stephen F. Templeton, MD Atlanta, Georgia
`
`Hereditary anetoderma
`Angela Peterman, MD, Monica Scheel, MD, W. Mitchell Sams, Jr., MD, and
`Amit G. Pandya, MD Dallas, Texas, and Birmingham, Alabama
`
`Superficial cutaneous Nocardia asteroides in an immunocompetent
`pregnant woman
`
`Georgia A. Kannon, MD, Melanie K. Kuechle, MD, and Algin B. Garrett, MD
`Richmond, Virginia
`
`Psoriasis and blue sclerae in girls with Turner syndrome
`Catherine Dac0u—Voutetakis, MD, and Talia Kakourou, MD Athens, Greece
`
`CURRENT ISSUES
`
`Primary care in dermatology: Whose role should it be?
`David L. Ramsay, MD, MEd, and Peyton E. Weary, MD
`New York, New York, and Charlottesville, Virginia
`
`The dermatologist’s role in primary care: A primary care physician’s
`View
`
`Barry L. Hainer, MD Charleston, South Carolina
`
`EDITORIALS
`
`Lifetime risk for development of skin cancer in the U.S. population:
`Current estimate is now 1 in S
`
`Darrell S. Rigel, MD, Robert J. Friedman, MD, and Alfred W. Kopf, MD
`New York, New York
`
`Surgical margins for malignant melanoma: Another point of View
`Matthew H. Kanzler, MD, and Susan M. Swetter, MD Stanford, California
`
`JOurnal of the American Academy of Dermatology
`
`Continued on page 13A
`December 1996
`11A
`
`A
`
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`

`a“‘ontents
`
`continued
`
`CORRESPONDENCE
`
`Lentigo maligna and lentigo maligna melanoma
`John H. Altshuler, MD Englewood, Colorado
`
`Reply
`Lisa M. Cohen, MD Boston, Massachusetts
`
`Benign melanocytic lesions
`Robin Marks Victoria, Australia
`
`Reply
`Peter J. Heenan and Theresa M. Skender-Kalnenas
`Nedlands, Western Australia
`
`Benign melanocytic lesions
`S. Elizabeth Whitmore, MD Baltimore, Maryland
`
`Reply
`Peter J. Heenan and Theresa M. Skender—Ka1nenas
`Nedlands, Western Australia
`
`Cyclosporine and angiogenesis in psoriasis
`Vincent W. Li, MD, and William W. Li, MD Cambridge, Massachusetts
`
`Reply
`E. P. Prens, MD, PhD, and R. Debets, PhD Rotterdam, The Netherlands
`
`Cutaneous reactions to recombinant cytokine therapy
`Manuela Papini, MD, and Pier Luigi Bruni, MD Terni, Italy
`
`Reply
`Anthony A. Gaspari, MD Rochester, New York
`
`Understanding and evaluating clinical trials
`Bruce G. Howard, MD Santa Maria, California
`
`READER SERVICES
`
`Index
`
`Author index
`
`Subject index
`
`Information for authors
`
`Information for readers
`
`Dermatology calendar
`
`1025
`
`1037
`
`23A, 24A, and 25A
`
`26A
`
`77A
`
`Jozfrnal of the American Academy of Dermatology
`
`Continued on page 14A
`
`December 1996
`
`13A
`
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`

`continued
`Contents
`
`
`Dermatology opportunities
`
`Instructions for Category I CME Credit
`
`CME examination answer sheet
`
`CME examination for volume 36
`
`CME examination answer sheet for volume 36
`
`Answers to CME examination for Volume 36
`
`Index to advertisers
`
`Complimentary subscriptions to the Journal of the American Academy of Dermatology are
`available to dermatology residents, fellows, and osteopathic trainees in the United States
`and Canada as an educational service by Westwood Squibb Pharmaceuticals, a division
`of Bristol—Myers Squibb Company.
`
`14A December 1996
`
`Journal of the American Academy of Dermatology
`
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`

`This material may be protected by Copyright law (Title 17 U.S. Code)
`
`
`
`Treatment of Candida nail infection with terbinafine
`
`Rina Segal, MD,“ Aharon Kritzman, MD,“ Lia Cividalli, PhD,b Zinira Samra, PhD,” and
`Michael David, MD“ Peta/1 Tiqva, Israel
`
`Background: Terbinafine is a highly potent drug against dermatophytes. Data regarding its
`effectiveness against Candida species are few and variable.
`Objective: Our puipose was to evaluate the efficacy and safety of oral terbinafme in patients
`with Candida nail infection.
`Methods: In an open—label uncontrolled study, 20 patients completed 16 weeks of treatment
`with terbinafine, 250 mg/day, and an additional 8 weeks with placebo. Efficacy was assessed
`clinically and mycologically at weeks 0 (baseline), 4, 8, 16, 24, 36, and 48. Routine labora-
`tory studies were performed at baseline and weeks 4, 8, and 16.
`Results: At the end of the trial 60% of target nails were cured clinically and mycologically;
`in 10% there was mycologic cure with residual clinical signs, in 25% a moderate improve-
`ment (>50%), and failure in only 5% (one patient). Most nails were infected by Candida
`parapsilosis. Two of 28 patients showed mild reversible elevation of liver enzymes 1 month
`after initiation of terbinafine treatment.
`Conclusion: The administration of terbinafme for l6 weeks is effective in the treatment of
`Candida nail infection. Liver enzyme values should be determined during the first month of
`treatment.
`
`(J Am Acad Dermatol l996;35:958—61.)
`
`The role of Candida species as a cause of nail
`disease has been well established} They cause 1%
`to 32% of toenail infections and 51% to 70% of fin—
`
`gemail infections, either as the sole pathogen or in
`combination with derinatophytes or molds.“
`Candida albicans accounts for 50%3 to 83%4 of
`
`Candida species causing nail infections, although C.
`parapsilosis is emerging now as the main pathogen
`in various centers.*
`
`Terbinafme is the first orally active antifungal
`drug of the allylamines class.5 The in vitro minimal
`inhibitory concentration values of terbinafine against
`dermatophytes are extremely low (0.001 to 0.01 ugl
`ml), but the in vitro activity against Candida is more
`variable and species dependent, ranging from 0.1 to
`12.5 pg/ml and even higher.6= 7 It
`is fungistatic
`
`From the Departments of Dennatology“ and Microbiology,l’ Beilinson
`Medical Centre, Petah Tikva, and the Sackler Faculty of Medicine,
`Tel—Aviv University.
`Supported by a grant from Sandoz Pharma Ltd, Basel, Switzerland.
`Reprint requests: Rina Segal. Department of Dermatology, Beilinson
`Medical Center. Pelali Tikva, 49100, Israel.
`*Abrainson C, Berlin S. Increased incidence of nondermatophyte file
`amentous fungi in skin and toenail infections. Abstracts of the Inter-
`national Suinmit on Cutaneous Antifungal Therapy, Boston, i994.
`Copyright © 1996 by the American Academy of Dermatology. Inc.
`0190-9622/96 $5.00 + 0
`16/l/74900
`
`958
`
`against C. albicans and fungicidal against C. para-
`psilosis.
`Numerous studies have confirmed the bC1'1CfiCl.
`effect of the drug against dermatophytes.5 However,
`there have been only a few reports on its efficacy
`against Candida nail infection. It was the purpose f
`this study to evaluate the efficacy and safety of oral
`terbinafine in patients with a nail infection caused by
`Candida species.
`
`PATIENTS AND NIETHODS
`
`canicd out as an open—labeled uncon-
`This study
`trolled study. The subjects had to have mycologicalljil
`proven candidal onychoinycosis, with or without parony—
`chial disease, to be older than 1 8 years of age, and to have
`the values of hematologic tests and blood chemist‘?
`within the normal range. All gave informed consent. EX-
`cluded from the trial were pregnant or lactating womt 1,
`patients with a history of peptic ulcer, renal or hepatic
`dysfunction, immunosuppressed patients with psoriasis
`or other dennatoses, and patients who had received sy
`temic antifungal therapy during the preceding 6 week8.
`The study was divided into two phases. In phase A.
`terbinafine, 250 ing/day, was given for 16 weeks. In pha 8
`B, a placebo was given for an additional 8 week?»
`followed by an off-treatment period of 24 weeks. Patiems
`were assessed mycologically every 4 weeks for the fi ~11
`24 weeks and every 12 weeks in the remaining 24 weeks.
`
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`

`Journal of the American Academy of Dermatology
`Volume 35, Number 6
`
`Sega! et al.
`
`959
`
`Table I. Response to treatment with terbinafine in Candida onychomycosis
`Week 24
`
`Target
`
`Finger-
`
`Complete cure
`Mycologic cure or marked
`improvement (>90%)
`Moderate improvement
`(>50%—<90%)
`Failure (<50%)
`
`2
`1
`
`10
`5
`
`3
`4
`
`15.5
`21
`
`6303
`
`15.5
`
`0
`0
`
`4
`
`30421001260
`1563115210
`
`21
`
`352101053 525
`
`1155948
`
`579
`
`420738 8421531553
`
`Target nail = 17 fingernails, 3 toenails; fingernails = (other than target nails), in 19 patients; toenails = (other than target nails) in 19 patients.
`
`Method of assessment
`
`Before treatment, the location of each nail infection
`
`was identified and a target nail was selected for mycologic
`testing and clinical evaluation. All the other infected nails
`were also assessed clinically at each visit. At each visit,
`the percentage of nail involvement was recorded and the
`
`severity of hyperkeratosis, color changes, and paronychial
`inflammation were graded on a 0 to 3 scale (0 = none;
`1 = mild; 2 = moderate; 3 = severe) for each nail. The
`mycologic examination of the target nail included potas-
`sium hydroxide (KOH) wet mount, culture on Sabouraud
`media with chloramphenicol, with and without actidione,
`and identification of candidal species. The clinical re-
`'-tponse was evaluated statistically with the following
`scale:
`
`1 = Complete cure: No residual clinical signs and nega-
`tive results of mycologic examination
`'.?.a = Mycologic cure for target nail, with mild residual
`clinical signs but negative culture and microscopic
`findings
`2b = Marked improvement for all nails other than the tar-
`get nail, with more than 90% clinical improvement
`= Moderate improvement: Clinical signs and symptoms
`decreased by more than 50% and less than 90%
`4 = Failure: Clinical improvement of less than 50%
`
`Statistical analysis
`
`The average improvement per week of the target nail,
`"angemails, and toenails was calculated. The results were
`analyzed with the two-sample I test for difference in
`means. The t test retains the null hypothesis at the 0.05
`lsvel of significance.
`RES ULTS
`
`Of the 28 patients who entered the study, eight did
`not complete it: two (7%) because of a reversible
`Lver enzyme elevation after 1 month of medication,
`t-vo because of dizziness and nausea, and four
`
`because of lack of compliance. Of the 20 patients
`who completed the 48 weeks of the study, 13 were
`women and 7 were men (age range, 21 to 68 years
`[mean, 49.9 years]). In these subjects, the side effects
`were gastric fullness (two) and dizziness (one).
`Table I presents the response to treatment of the
`target nail and all other fingernails (in 19 patients)
`and toenails (in 19 patients; five also grew Trich0—
`phylon rubrum). At the end of the study, 12 target
`nails (60%) were cured, in two (10%) there was a
`mycologic cure, in 5 there was moderate improve-
`ment, and treatment failed in 1. Of the three target
`toenails, one was cured and two showed moderate
`
`improvement (>80%). A similar response was ob-
`served in the infected fingernails (Table 1). The re-
`sponse of the toenails was less favorable and
`improvement was observed only after a longer time,
`with a complete cure or marked improvement
`(>90%) in only 49%. Overall, of a total of 75 affected
`fingernails, 58 (77%) were cured; 85 (67.5%) of the
`126 infected toenails were cured.
`
`In 18 of the 20 target nails it was possible to iden-
`tify the candidal species (Table ll). Only three
`patients were infected with C. albicans and in two of
`
`them C. parapsilosis was also isolated. C. pumps!"-
`losis was found in 16 of 18 nails: six of them alone
`
`and in the rest, in combination with C. albicans
`
`lypolytica, C.
`tropicalis (four), or C.
`(two), C.
`fimlata, or C. mgosa (four). C. tropicalis alone was
`identified in only one patient. C. parapsilosis and C.
`tropicalis infection was manifested mainly as pri-
`mary distal and lateral onychodystrophy. Total nail
`involvement was observed in five patients; three of
`them had paronychial involvement.
`Mycologic cure (negative potassium hydroxide
`and culture) was obtained in 18 patients after a mean
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`

`960 Segal er al.
`
`Journal of the American Academy of Dermatology
`December 1996
`
`Table II. Distribution of Candida species, type of clinical infection, and response to treatment
`
`Type of clinical infection
`
`Time of
`
`Proximal
`nail onychia
`
`nail onychia
`
`Total nail
`involvement
`
`mycologic cure
`(Wk)
`
`Response to treatment (week 48)
`(scale of response)*
`
`C. albicans
`
`C. parapsilosis
`C. tropicalis
`C. albicans, and
`C. parapsilosis
`C. parapsilosis and
`C. tropicalis
`C. parapsilosis and
`C. lypotica,
`C. fimtata, or
`C. mgosa
`
`*Scale of response: 1 = Cure; 2a : mycologic cure; 3 = modcrate improvement; 4 = failure.
`TTotal nail involvement with paronychia.
`:tTwo patients did not achieve mycologic cure.
`
`time of 25.8 i 2.3 weeks (range, 4 to 40 weeks)
`(Table 11). The mycologic cure time for C. albicans
`was 37.7 weeks and for C. parapsilosis and C. trop-
`icalis was an average of 22 to 24 weeks. The com—
`bination of C. lypolytica, C. fumata, or C. rugosa
`lengthened the time for mycologic cure to an aver-
`age of 30.6 weeks. The most rapid response was in
`infections caused by C. parapsilosis, whereas the
`response by C. albicans was obvious only after 24
`weeks of treatment.
`
`During the follow—up period of 8 months only one
`patient had a relapse and this occurred at approxi-
`mately 48 weeks.
`
`DISCUSSION
`
`terbinafine for 3 months
`Therapy with oral
`produces a cure rate of more than 80% in der-
`matophytosis of the nails.8 For candidial nail infec-
`tions, however, differing results have been report-
`ed_9, 10
`
`infections
`Our results showed that fingernail
`responded better to terbinafine than toenail infec-
`tions. The continuing clinical and mycologic im-
`provement after cessation of treatment and the rela-
`tively low relapse rate imply that terbinafme contin-
`ues to be active in the nailplate for more than 6
`months. However, no studies have been done of the
`
`presence of terbinafine in the nailpl ate more than 90
`days after its discontinuation.‘ ‘= 12
`Onychomycosis caused by Candida species is
`relatively frequent in Israel. In our study group, C.
`
`parapsilosis was more common than C. albicans as
`the pathogen. Most patients had distal nail dystro-
`phy; none of them had peripheral vascular disease.
`Evaluation after 16 weeks of treatment showed an
`
`earlier and better response to treatment by C. parap-
`silosis than by C. albicans, but after 48 weeks the ei :1
`results were almost identical. This pattern of ie.—
`sponse can be explained by the fact that terbinafme
`is fungicidal for C. parapsilosis and fungistatic Li‘
`C. albicans. Nails infected with rather rare species of
`Candida (C.
`lypolytica, C. fumata, C.
`rugosa)
`showed mild or moderate improvement. Unfortu-
`nately, we were unable to determine the minimal
`hibitory concentration values for the various species
`of Candida.
`
`Only two previous studies have evaluated the i‘-
`ficacy of terbinafine for Candida nail infection. The
`first by Roberts et al.9 gave terbinafine for 12 weeks
`or up to 24 weeks in nonresponders. The impron :-
`ment after 12 weeks was not significant, and fol-
`low—up results were not conclusive. Nolting, Brau—
`tigam, and Weidingerlo treated their patients for -3.8
`weeks. Clinical and mycologic cures were achieved
`in 52% of toenails and in 65% of fingernails. The
`cure rates according to pathogen were 63% for J.
`parapsilosis and 54% for C. albicans. Our results
`"6
`in accord with these.
`
`Overall, in our study terbinafine was well toler-
`ated. The only relevant adverse reaction was. a
`reversible elevation of liver enzymes in 2 (7%) of '78
`patients.
`
`CFAD V. Anacor, |PR20’|5-01776 ANACOR EX. 2050 - “IO/’|’|
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`CFAD v. Anacor, IPR2015-01776 ANACOR EX. 2050 - 10/11
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`

`

`Journal of the American Academy of Dermatology
`Volume 35, Number 6
`
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`CFAD v. Anacor, IPR2015-01776 ANACOR EX. 2050 - 11/11
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