Eighteen dogs with Malassezia dermatitis participated in a clinical trial to evaluate the efficacy of miconazole conditioners. Dogs were randomly assigned to receive vehicle only, miconazole 1%, or miconazole 2% conditioner. Conditioners were used three times weekly for 2 weeks and then twice weekly for 2 weeks. Investigators evaluated erythema, pruritus, and yeast counts weekly. Owners scored pruritus daily. Yeast number decreased in all treatment groups. Yeast number in the vehicle group was higher than in both the miconazole treatment groups but was not different between the two miconazole groups. Clinical scores decreased but no difference was detected among groups.

Disseminated infection with the fungal pathogen Penicillium marneffei is, after extrapulmonary tuberculosis and cryptococcal meningitis, the third most common opportunistic infection in HIV disease in northern Thailand. We report the clinical, microbiological, and therapeutic features of a large series of HIV-infected adults with disseminated P marneffei infection. From August, 1987, to June, 1992, 92 patients with P marneffei infection confirmed by culture were seen at Chiang Mai University Hospital, of whom 86 were also infected with HIV. Clinical information was available for 80 of these patients. The most common presenting symptoms and signs were fever (92%), anaemia (77%), weight loss (76%), and skin lesions (71%). 87% of patients presenting with skin lesions had generalised papules with central umbilication. Presumptive diagnosis was made in 50 patients by microscopic examination of Wright's-stained bone-marrow aspirate and/or touch smears of skin biopsy or lymph-node biopsy specimens. Most patients who were diagnosed responded initially to amphotericin or itraconazole, whereas most who were not diagnosed and treated died. 12 patients relapsed within 6 months of cessation of treatment. P marneffei has become an important pathogen of HIV-associated opportunistic infection in Thailand.

The recent introduction of a new generation of antifungal drugs promises to alter significantly therapy for both systemic and superficial mycoses, in particular, onychomycosis. This article presents an in-depth review of the azoles (the triazoles itraconazole and fluconazole), the allylamines (naftifine and terbinafine), and the morpholine derivative amorolfine.

The last decade has witnessed remarkable advances in the therapy for cutaneous fungal diseases. These will have a major impact on the choice of antifungal therapy. To understand these advances traditional therapies for fungal diseases, the polyenes, griseofulvin, older topical agents and the older azoles, will be reviewed first. Part II will focus on recent advances.

We report a case of disseminated Scedosporium apiospermum infection in a neutropenic patient with acute myeloid leukemia. Due to progression of the mycosis after 7 days of amphotericin B lipid complex therapy and to high susceptibility of the mold to voriconazole in vitro, the patient was treated with intravenous voriconazole. After a few days of therapy, fever disappeared and skin lesions improved. However, the patient died after 1 month due to intestinal bleeding. Despite a negative outcome, this case seems to indicate a promising role for voriconazole in the treatment of S. apiospermum infections.

PURPOSE: The purpose of this study was to assess the tolerance and efficacy of itraconazole in the treatment of coccidioidomycosis. PATIENTS AND METHODS: Fifty-one patients with nonmeningeal coccidioidomycosis were considered for treatment with intraconazole. Forty-nine patients who met study criteria were treated with itraconazole given orally in doses of 100 to 400 mg/day for periods up to 39 months. Of these patients, 12 had osteoarticular disease, 23 had chronic pulmonary disease, and 14 had skin or soft tissue disease. Clinical response was evaluated using a scoring system accounting for lesion number and size, symptoms, culture, and serologic titer. Remission was defined as reduction of the pretreatment score by 50% or more. RESULTS: Patients with osteoarticular, chronic pulmonary, and soft tissue disease improved at similar rates. Because two patients had no scoring assessment for efficacy, they were considered inassessable for efficacy. Forty-seven patients are evaluable. Of these patients, 44 have completed therapy, and three are still receiving itraconazole. Of the 44 patients no longer receiving therapy, 25 (57%) achieved remission. Of the 25 patients achieving remission, four later experienced a relapse. Therapy failed in 19 patients (43%). Of these cases, 16 (36%) were clinical failures and three (7%) developed drug intolerance that precluded continuation of treatment. Evaluation of culture conversions was of limited value in the osteoarticular patients, fewer than half of whom had follow-up biopsies. However, culture conversions were a useful index of response in patients with chronic pulmonary disease. During the course of treatment, serologic titers declined in the two groups with extrapulmonary disease, but not in patients with pulmonary coccidioidomycosis. Possible toxicities were generally mild. CONCLUSION: Itraconazole appears efficacious and very well tolerated in patients with coccidioidomycosis.

BACKGROUND: Itraconazole is a broad-spectrum antifungal agent that has been used to treat dermatomycosis and onychomycosis using continuous therapy. More recently the drug has been used as pulse dosing. OBJECTIVE: Our purpose was to review the studies in which itraconazole pulse therapy (PT) has been administered in the management of dermatomycoses. RESULTS: For tinea pedis and manuum, the recommended dosage is itraconazole 200 mg twice daily for 1 week (n = 220). A clinical response and mycologic cure rate of 90%+/- 4% and 76%+/- 6%, respectively, has been obtained. For tinea corporis/cruris, itraconazole 200 mg/day for 1 week (n = 354) resulted in a clinical response and mycologic cure rate of 90%+/- 4% and 77%+/- 6%, respectively. When three pulses of itraconazole are used to treat toenail onychomycosis (n = 1389), the clinical cure rate, clinical response, and mycologic cure rate at follow-up 12 months after the start of therapy were 58%+/- 10%, 82%+/- 3%, and 77%+/- 5%, respectively. With two pulses for onychomycosis of the fingernails, the clinical cure rate, clinical response, and mycologic cure rate at follow-up, 9 months after the start of therapy, were 78%+/- 10%, 89%+/- 6%, and 87%+/- 8%, respectively. CONCLUSION: Itraconazole PT is effective and safe in the treatment of tinea pedis/manuum, tinea corporis/cruris, and onychomycosis.