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P6193 Onychomycosis in children: Clinicomycologic study of 216 patients from Ibn-Sina University Hospital, Rabat Nada Srifi, MD, MD, Dermatology Department, Ibn-Sina University Hospital, Rabat, Morocco; Badredine Hassam, PhD, Dermatology Department, Ibn-Sina University Hospital, Rabat, Morocco; Karima Senouci, PhD, Dermatology Department, Ibn-Sina University Hospital, Rabat, Morocco; Mohamed Aitourhroui, PhD, Dermatology Department, Ibn-Sina University Hospital, Rabat, Morocco; Nadia Ismaili, PhD, Dermatology Department, Ibn-Sina University Hospital, Rabat, Morocco; Yasmina Ouidan, MD, Dermatology Department, Ibn-Sina University Hospital, Rabat, Morocco Background: Onychomycosis in children is relatively uncommon. This survey was carried out to estimate the frequency and clinicomycologic aspects of fungal nail infections in children and adolescents ( \18 years of age) attending our department. Methods: This is a prospective study conducted between September 2008 and December 2010 in the dermatology department of ibn-Sina University Hospital in Rabat, Morocco. 216 patients suspected of superficial fungal infection were included. 196 patients presented an onychomycosis. 31 patients were aged between 7 and 18 years. Results: Onychomycosis caused by dermatophytes was demonstrated in 25 cases. Trichophyton rubrum (17 cases) was the most prevalent species, followed by Trichophyton mentagrophytes var. interdigitale (5 cases) and T mentagrophytes var. mentagrophytes (3 cases). Onychomycosis caused by Candida albicans was demonstrated in 6 patients. Distal and lateral subungual onychomycosis was the most common clinical pattern. Proximal white superficial onychomycosis was found in 8 cases. Discussion: There are few reports studying the etiology of onychomycosis in children. The prevalence of onychomycosis in children is \1%, but it tends to increase over the years and represent 15.5% of all nail dystrophies in children. T rubrum is the most common causative agent of onychomycosis. Differential diagnoses in children include psoriasis, alopecia areata, eczema, congenital nail dystrophy, parakeratosis pustulosa, and trauma. Conclusion: Our study shows that onychomycosis in children is rare but not exceptional and should be diagnosed by performing a mycologic study. Commercial support: None identified. P6713 Atopic dermatitis and ichthyosis with generalized scaly erythematous skin lesions difficult to control: An unexpected diagnosis Mar ıa Salazar Nievas, San Cecilio Hospital, Granada, Spain; Jacinto Orgaz Molina, San Cecilio Hospital, Granada, Spain; Jose Aneiros Fernandez, San Cecilio Hospital, Granada, Spain; Salvador Arias Santiago, San Cecilio Hospital, Granada, Spain Background: Patients with topical dermatitis have a tendency to suffer skin infections, for alteration of the defensive barrier of the skin. The most common are the bacterial ones, but also they can be caused by other microorganisms. Case report: A 56-year-old man who had personal history of sex-linked recessive ichthyosis and atopic long evolution dermatitis was derived from another hospital. The reason for this derivation was that the patient had generalized injuries that were interpreted as an outbreak of atopic dermatitis, and they had not improved despite the treatment with oral corticosteroids and topical immunomodulators. The examination revealed the presence of generalized scaly-erythematous injuries, affecting the entire integument including face. Palms and plants of the feet were not damaged. The patient is stable, afebrile, with much itching and flaking that diminish their quality of life. Based on the poor prognosis and clinical characteristics of the disease, it was decided that punch biopsies would be done on the right arm. The pathologic report identified, by Giemsa technique and methenamine silver, fungal structures (hyphae and spores) located in the stratum corneum. Afterwards it was obtained a culture of skin scales, in which Trichophyton mentagrophytes was grown. The patient was treated with terbinafine 250 mg daily for 1 month with excellent improvement of both the scaling and erythema. We present a strange case of tinea corporis generalized in the context of atopic dermatitis and ichthyosis. The association of ichthyosis and atopic dermatitis is as uncommon as Netherton syndrome, also associated with trichorrhexis invaginata. Our patient had a gener- alized scaling and an important erythema caused by the significant inflammatory component that generates the T mentagrophytes. The improvement was spectac- ular when the producing agent was treated. We emphasize the importance of suspecting a fungal infection in patients with ichthyosis and atopic dermatitis who did not improve with the treatment. Commercial support: None identified. P6584 Successful treatment of onychomycosis caused by Scytalidium dimidia- tum by long-pulsed 1064 nm Nd:YAG laser and combination of laser treatment and 5% amorolfine nail lacquer: A case report Sumanas Bunyaratavej, MD, Department of Dermatology, Faculty of Medicine, Siriraj Hospital Mahidol University, Bangkok, Thailand; Chanai Muanprasart, Department of Dermatology, Faculty of Medicine, Siriraj Hospital Mahidol University, Bangkok, Thailand; Kanchalit Thanomkitti, MD, Department of Dermatology, Faculty of Medicine, Siriraj Hospital Mahidol University, Bangkok, Thailand; Lalita Matthapan, Department of Dermatology, Faculty of Medicine, Siriraj Hospital Mahidol University, Bangkok, Thailand; Rungsima Wanitphakdeedecha, MD, Department of Dermatology, Faculty of Medicine, Siriraj Hospital Mahidol University, bangkok, Thailand; Sasima Eimpunth, MD, Department of Dermatology, Faculty of Medicine, Siriraj Hospital Mahidol University, Bangkok, Thailand; Woraphong Manuskiatti, MD, Department of Dermatology, Faculty of Medicine, Siriraj Hospital Mahidol University, Bangkok, Thailand Background: Nondermatophyte mold onychomycosis is a considerably greater diag- nostic challenge and more difficult to treat than dermatophytic onchomycosis. Scytalidium dimidiatum is a dematiaceous fungus that is commonly found in Thailand and responds poorly to antifungals. Laser treatment in onychomycosis is mainly used in cases of dermatophytic onychomycosis with effective results and safety. The objective is to report the successful treatment of S dimidiatum toenail infection by 1064 nm Nd:YAG laser and combination of the laser and 5% Amorolfine nail lacquer. Methods: A 43-year-old Thai woman presented with both clinical features of distal and lateral subungual onychomycosis and proven mycological tests of 4 toenails infected by S dimidiatum for 6 months. Her nails progressed gradually and displayed nail discoloration. Fungal culture repeated several times from all infected toenails revealed S dimidiatum without presence of dermatophytes. Initially, all infected nails were treated with a once weekly interval regimen of 2 passes long-pulsed 1064 nm Nd:YAG laser (35-45 J/cm 2 of fluence, 30-35 msec of pulse duration, 4 mm of spot size and 1 Hz of frequency) for 4 weeks as a first cycle of treatment. Her nail specimens were also obtained for microscopic examination and fungal culture before each weekly laser treatment. The second cycle was started 1 month later after end of the first cycle unless culture negative. The second cycle regimen was the same as the first cycle regimen. Results: The patient achieved both clinical and mycologic cure of the 2 toenails (right big toe and left third toenail) after the end of the second cycle; noticeably, the right big toe was completely cured after only the first cycle. The other 2 infected nails (left big toe and left second toenail) remained positive on microscopy and fungal culture of S dimidiatum. For the 2 recalcitrant infected nails, once weekly 5% amorolfine nail lacquer for 4 weeks was added adjunctly with the third cycle of laser treatment on a weekly basis. After completing the third cycle, all nails slowly changed into normal toenails with negative culture up to 10 months throughout present follow-up. No serious side effects of the treatment were detected except mild tolerable pain during laser treatment. Conclusion: Long-pulsed 1064 nm Nd:YAG laser treatment onychomycosis and/or the laser with combination with 5% amorolfine nail lacquer was effective and safe for treatment of nondermatophyte onychomycosis from S dimidiatum. Commercial support: None identified. P6853 Tinea nigra palmaris: Case report and diagnostic options Stella Ramos-e-Silva, MD, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Celso Sodre, MD, PhD, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Clarice Jordao, MD, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Felipe Nazareth, MD, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Gabriela Campos, MD, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil Background: Tinea nigra, also known as keratomycosis nigricans palmaris, is a benign superficial infection that affects the stratum corneum of the skin and is often asymptomatic. The clinical symptoms include brown to black pigmented macules that enlarge centrifugally, with dark edges and without scaling which appears on the palms of the hands and soles of the feet. It was considered a restricted disease of the tropical and subtropical areas, being most common in South America, Central America, Africa and Asia, but recently there have been reports in regions of temperate climate such as Britain, France, Spain and USA. Case report: We report a case of a 21-year-old man who sought care with an asymptomatic hyperpigmented brown lesion on the right hand with in course for 5 years. He reported that when he tried to rub the area using pumice sponge, the lesion disappeared almost completely, but soon return, a few months or even weeks after. Dermatoscopic examination was realized and presented evidence of typical pig- mented spicules. Material was collected by scraping with a glass the edges of the lesion for direct microscopic examination of scales and realization of culture in Sabouraud agar with chloramphenicol. The direct microscopic examination revealed the presence of septate hyphae dematiaceous and culture showed black colonies of the fungus identified as Hortaeae werneckii, closing the diagnosis of tinea nigra palmaris. Discussion: Tinea nigra is easy to diagnose but can also be easily confused with pigmented lesions such as acral nevi or melanoma, postinflammatory hyperpig- mentation, fixed drug eruptions or chemical stains. Rapid diagnosis can be made by skin scrapings KOH microscopic examination that find pigmented hyphae and is confirmed by growth of a dematiaceous mold on culture media. Digital dermatos- copy is a noninvasive auxiliary method that can also improve the diagnosis, showing the regularly distributed pigmented spicules of tinea nigra different from the pigment network of melanocytic lesions. The disorder can be easily treated with topical antifungal therapy. Despite being more common in countries of tropical and subtropical climates, tinea nigra has been also found in regions where the climate is not necessarily the great enabler of development. Commercial support: None identified. AB130 JAM ACAD DERMATOL APRIL 2013

Successful treatment of onychomycosis caused by Scytalidium dimidiatum by long-pulsed 1064 nm Nd:YAG laser and combination of laser treatment and 5% amorolfine nail lacquer: A case

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Page 1: Successful treatment of onychomycosis caused by Scytalidium dimidiatum by long-pulsed 1064 nm Nd:YAG laser and combination of laser treatment and 5% amorolfine nail lacquer: A case

P6193Onychomycosis in children: Clinicomycologic study of 216 patients fromIbn-Sina University Hospital, Rabat

Nada Srifi, MD, MD, Dermatology Department, Ibn-Sina University Hospital,Rabat, Morocco; Badredine Hassam, PhD, Dermatology Department, Ibn-SinaUniversity Hospital, Rabat, Morocco; Karima Senouci, PhD, DermatologyDepartment, Ibn-Sina University Hospital, Rabat, Morocco; MohamedAitourhroui, PhD, Dermatology Department, Ibn-Sina University Hospital,Rabat, Morocco; Nadia Ismaili, PhD, Dermatology Department, Ibn-SinaUniversity Hospital, Rabat, Morocco; Yasmina Ouidan, MD, DermatologyDepartment, Ibn-Sina University Hospital, Rabat, Morocco

Background: Onychomycosis in children is relatively uncommon. This survey wascarried out to estimate the frequency and clinicomycologic aspects of fungal nailinfections in children and adolescents (\18 years of age) attending our department.

Methods: This is a prospective study conducted between September 2008 andDecember 2010 in the dermatology department of ibn-Sina University Hospital inRabat, Morocco. 216 patients suspected of superficial fungal infection wereincluded. 196 patients presented an onychomycosis. 31 patients were aged between7 and 18 years.

Results: Onychomycosis caused by dermatophytes was demonstrated in 25 cases.Trichophyton rubrum (17 cases) was the most prevalent species, followed byTrichophyton mentagrophytes var. interdigitale (5 cases) and T mentagrophytesvar. mentagrophytes (3 cases). Onychomycosis caused by Candida albicans wasdemonstrated in 6 patients. Distal and lateral subungual onychomycosis was themost common clinical pattern. Proximal white superficial onychomycosis wasfound in 8 cases.

Discussion: There are few reports studying the etiology of onychomycosis inchildren. The prevalence of onychomycosis in children is \1%, but it tends toincrease over the years and represent 15.5% of all nail dystrophies in children. Trubrum is the most common causative agent of onychomycosis. Differentialdiagnoses in children include psoriasis, alopecia areata, eczema, congenital naildystrophy, parakeratosis pustulosa, and trauma.

Conclusion: Our study shows that onychomycosis in children is rare but notexceptional and should be diagnosed by performing a mycologic study.

AB130

cial support: None identified.

Commer

P6713Atopic dermatitis and ichthyosis with generalized scaly erythematous skinlesions difficult to control: An unexpected diagnosis

Mar�ıa Salazar Nievas, San Cecilio Hospital, Granada, Spain; Jacinto Orgaz Molina,San Cecilio Hospital, Granada, Spain; Jose Aneiros Fernandez, San CecilioHospital, Granada, Spain; Salvador Arias Santiago, San Cecilio Hospital,Granada, Spain

Background: Patients with topical dermatitis have a tendency to suffer skininfections, for alteration of the defensive barrier of the skin. The most commonare the bacterial ones, but also they can be caused by other microorganisms.

Case report: A 56-year-old man who had personal history of sex-linked recessiveichthyosis and atopic long evolution dermatitis was derived from another hospital.The reason for this derivation was that the patient had generalized injuries that wereinterpreted as an outbreak of atopic dermatitis, and they had not improved despitethe treatment with oral corticosteroids and topical immunomodulators. Theexamination revealed the presence of generalized scaly-erythematous injuries,affecting the entire integument including face. Palms and plants of the feet werenot damaged. The patient is stable, afebrile, with much itching and flaking thatdiminish their quality of life. Based on the poor prognosis and clinical characteristicsof the disease, it was decided that punch biopsies would be done on the right arm.The pathologic report identified, by Giemsa technique and methenamine silver,fungal structures (hyphae and spores) located in the stratum corneum. Afterwards itwas obtained a culture of skin scales, in which Trichophyton mentagrophytes wasgrown. The patient was treated with terbinafine 250 mg daily for 1 month withexcellent improvement of both the scaling and erythema. We present a strange caseof tinea corporis generalized in the context of atopic dermatitis and ichthyosis. Theassociation of ichthyosis and atopic dermatitis is as uncommon as Nethertonsyndrome, also associated with trichorrhexis invaginata. Our patient had a gener-alized scaling and an important erythema caused by the significant inflammatorycomponent that generates the T mentagrophytes. The improvement was spectac-ular when the producing agent was treated. We emphasize the importance ofsuspecting a fungal infection in patients with ichthyosis and atopic dermatitis whodid not improve with the treatment.

cial support: None identified.

Commer

J AM ACAD DERMATOL

P6584Successful treatment of onychomycosis caused by Scytalidium dimidia-tum by long-pulsed 1064 nm Nd:YAG laser and combination of lasertreatment and 5% amorolfine nail lacquer: A case report

Sumanas Bunyaratavej, MD, Department of Dermatology, Faculty of Medicine, SirirajHospital Mahidol University, Bangkok, Thailand; Chanai Muanprasart, Department ofDermatology, Faculty of Medicine, Siriraj Hospital Mahidol University, Bangkok,Thailand; Kanchalit Thanomkitti, MD, Department of Dermatology, Faculty ofMedicine, Siriraj Hospital Mahidol University, Bangkok, Thailand; Lalita Matthapan,Department of Dermatology, Faculty of Medicine, Siriraj Hospital Mahidol University,Bangkok, Thailand; Rungsima Wanitphakdeedecha, MD, Department of Dermatology,Faculty of Medicine, Siriraj Hospital Mahidol University, bangkok, Thailand; SasimaEimpunth, MD, Department of Dermatology, Faculty of Medicine, Siriraj HospitalMahidol University, Bangkok, Thailand; Woraphong Manuskiatti, MD, Department ofDermatology, FacultyofMedicine, SirirajHospitalMahidolUniversity,Bangkok,Thailand

Background: Nondermatophyte mold onychomycosis is a considerably greater diag-nostic challenge and more difficult to treat than dermatophytic onchomycosis.Scytalidium dimidiatum is a dematiaceous fungus that is commonly found inThailand and responds poorly to antifungals. Laser treatment in onychomycosis ismainly used in cases of dermatophytic onychomycosiswith effective results and safety.The objective is to report the successful treatment of S dimidiatum toenail infectionby 1064nmNd:YAG laser and combinationof the laser and5%Amorolfine nail lacquer.

Methods: A 43-year-old Thai woman presentedwith both clinical features of distal andlateral subungual onychomycosis and proven mycological tests of 4 toenails infectedby S dimidiatum for 6 months. Her nails progressed gradually and displayed naildiscoloration. Fungal culture repeated several times from all infected toenails revealedS dimidiatum without presence of dermatophytes. Initially, all infected nails weretreatedwith a onceweekly interval regimen of 2 passes long-pulsed 1064 nmNd:YAGlaser (35-45 J/cm2 of fluence, 30-35msec of pulse duration, 4mmof spot size and 1Hzof frequency) for 4 weeks as a first cycle of treatment. Her nail specimens were alsoobtained for microscopic examination and fungal culture before each weekly lasertreatment.The second cyclewas started 1month later after endof the first cycle unlessculture negative. The second cycle regimen was the same as the first cycle regimen.

Results: The patient achieved both clinical and mycologic cure of the 2 toenails(right big toe and left third toenail) after the end of the second cycle; noticeably, theright big toe was completely cured after only the first cycle. The other 2 infectednails (left big toe and left second toenail) remained positive on microscopy andfungal culture of S dimidiatum. For the 2 recalcitrant infected nails, onceweekly 5%amorolfine nail lacquer for 4 weeks was added adjunctly with the third cycle of lasertreatment on a weekly basis. After completing the third cycle, all nails slowlychanged into normal toenails with negative culture up to 10 months throughoutpresent follow-up. No serious side effects of the treatment were detected exceptmild tolerable pain during laser treatment.

Conclusion: Long-pulsed 1064 nm Nd:YAG laser treatment onychomycosis and/orthe laser with combinationwith 5% amorolfine nail lacquer was effective and safe fortreatment of nondermatophyte onychomycosis from S dimidiatum.

cial support: None identified.

Commer

P6853Tinea nigra palmaris: Case report and diagnostic options

Stella Ramos-e-Silva, MD, Universidade Federal do Rio de Janeiro, Rio de Janeiro,Brazil; Celso Sodre, MD, PhD, Universidade Federal do Rio de Janeiro, Rio deJaneiro, Brazil; Clarice Jordao, MD, Universidade Federal do Rio de Janeiro, Rio deJaneiro, Brazil; Felipe Nazareth, MD, Universidade Federal do Rio de Janeiro, Riode Janeiro, Brazil; Gabriela Campos, MD, Universidade Federal do Rio de Janeiro,Rio de Janeiro, Brazil

Background: Tinea nigra, also known as keratomycosis nigricans palmaris, is abenign superficial infection that affects the stratum corneum of the skin and is oftenasymptomatic. The clinical symptoms include brown to black pigmented maculesthat enlarge centrifugally, with dark edges and without scaling which appears on thepalms of the hands and soles of the feet. It was considered a restricted disease of thetropical and subtropical areas, being most common in South America, CentralAmerica, Africa and Asia, but recently there have been reports in regions oftemperate climate such as Britain, France, Spain and USA.

Case report: We report a case of a 21-year-old man who sought care with anasymptomatic hyperpigmented brown lesion on the right hand with in course for 5years. He reported that when he tried to rub the area using pumice sponge, the lesiondisappeared almost completely, but soon return, a few months or even weeks after.Dermatoscopic examination was realized and presented evidence of typical pig-mented spicules.Materialwas collected by scrapingwith a glass the edges of the lesionfor direct microscopic examination of scales and realization of culture in Sabouraudagar with chloramphenicol. The direct microscopic examination revealed thepresence of septate hyphae dematiaceous and culture showed black colonies of thefungus identified asHortaeae werneckii, closing the diagnosis of tinea nigra palmaris.

Discussion: Tinea nigra is easy to diagnose but can also be easily confused withpigmented lesions such as acral nevi or melanoma, postinflammatory hyperpig-mentation, fixed drug eruptions or chemical stains. Rapid diagnosis can be made byskin scrapings KOH microscopic examination that find pigmented hyphae and isconfirmed by growth of a dematiaceous mold on culture media. Digital dermatos-copy is a noninvasive auxiliary method that can also improve the diagnosis, showingthe regularly distributed pigmented spicules of tinea nigra different from thepigment network of melanocytic lesions. The disorder can be easily treated withtopical antifungal therapy. Despite being more common in countries of tropical andsubtropical climates, tinea nigra has been also found in regions where the climate isnot necessarily the great enabler of development.

cial support: None identified.

Commer

APRIL 2013