Toma de muestras y examen directo en dermatomicosis / Sample Taking and Direct Examination in Dermatomycoses

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Enfermedades inflamatorias mediadas por inmunidad y otras comorbilidades en pacientes con psoriasis. Características basales de la cohorte de pacientes con psoriasis del estudio AQUILES / Immune-Mediated Inflammatory Diseases and Other Comorbidities in Patients With Psoriasis: Baseline Characteristics of Patients in the AQUILES Study

Introducción y objetivos: Los pacientes con psoriasis presentan con frecuencia comorbilidades, incluyendo otras enfermedades inflamatorias mediadas por inmunidad (EIMI) y factores de riesgo cardiovascular (FRCV). El objetivo de este trabajo es describir la prevalencia basal de otras EIMI y comorbilidades en una cohorte de pacientes con psoriasis. Pacientes y métodos: AQUILES es un estudio observacional prospectivo multicéntrico de 3 cohortes de pacientes (psoriasis, espondiloartritis y enfermedad inflamatoria intestinal [EII]), para evaluar la coexistencia de EIMI y otras comorbilidades. En la cohorte con psoriasis se incluyeron pacientes ≥ 18 años atendidos en consultas hospitalarias de dermatología. Se recogió información sobre datos demográficos y clínicos de acuerdo a un protocolo preespecificado. Resultados: Se incluyeron 528 pacientes con psoriasis (edad media: 46,7 años; 60,2% hombres; 39,8% mujeres; 89,8% psoriasis en placas; mediana de PASI 3,2 [1,5-7,4]). Presentaron otra EIMI 82 pacientes (15,5% [IC 95%: 12,7-18,9]). El 14,0% (IC 95%: 11,3-17,2) presentó espondiloartritis (la mayoría de estos artritis psoriásica [prevalencia 13,1%, IC 95%: 10,5-16,2), el 1,3% EII (IC 95%: 0,6-2,7) y el 0,2% uveítis (IC 95%: 0,1-1,4). La presencia de artritis psoriásica se asoció al sexo masculino (OR: 1,75 [0,98-2,98]) y a la duración de la psoriasis > 8 años (OR: 4,17; [1,84- 9,44]) respecto a < 4 años. El 73,1% presentó al menos un FRCV: tabaquismo (40,5%); obesidad (26,0%); dislipidemia (24,8%); hipertensión arterial (24,3%) y diabetes mellitus (12,3%). Conclusión: Los pacientes con psoriasis presentaron una prevalencia del 15,5% de otras EIMI, discretamente superior a la de población general. Casi tres cuartas partes tuvieron al menos un FRCV (AU)

Introduction and objectives: Patients with psoriasis often have comorbidities, including other immune-mediated inflammatory diseases (IMIDs), and cardiovascular risk factors. In this article we describe the baseline prevalence of comorbidities----including other IMIDs----in a cohort of patients with psoriasis. Patients and methods: AQUILES was a prospective observational multicenter study of 3 patient cohorts (patients with psoriasis, spondyloarthritis, or inflammatory bowel disease) undertaken to investigate the prevalence of comorbidities, including other IMIDs, in these settings. The psoriasis cohort comprised patients aged at least 18 years who were seen in hospital dermatology clinics. A predefined protocol was used to collect demographic and clinical data. Results: The study enrolled 528 patients with psoriasis (60.2% men and 39.8% women). Mean age was 46.7 years; 89.8% of the participants had plaque psoriasis, and the median Psoriasis Area Severity Index score (PASI) was 3.2 (1.5-7.4). Comorbid IMIDs were present in 82 (15.5%) of the patients (CI 95%, 12.7%-18.9%). Spondyloarthritis was observed in 14% of patients (95% CI, 11.3%-17.2%), mostly in the form of psoriatic arthritis, for which the overall prevalence was 13.1% (95% CI, 10.5%-16.2%). Inflammatory bowel disease was present in 1.3% (95% CI, 0.6%-2.7%) and uveitis in .2% (95% CI, 0.1%-1.4%). Psoriatic arthritis was associated with male sex (odds ratio, 1.75 [.98-2.98]) and a disease duration of over 8 years (OR, 4.17 [1.84-9.44] vs a duration of < 4 years). In 73.1%, at least 1 cardiovascular risk factor was identified: smoking (40.5%), obesity (26.0%), dyslipidemia (24.8%), hypertension (24.3%), and diabetes mellitus (12.3%). Conclusion: In patients with psoriasis the prevalence of other IMIDs was 15.5%, a level slightly higher than that found in the general population. Nearly three-quarters of these patients had at least 1 cardiovascular risk factor (AU)

Immune-mediated inflammatory diseases and other comorbidities in patients with psoriasis: baseline characteristics of patients in the AQUILES study.

INTRODUCTION AND OBJECTIVES: Patients with psoriasis often have comorbidities, including other immune-mediated inflammatory diseases (IMIDs), and cardiovascular risk factors. In this article we describe the baseline prevalence of comorbidities-including other IMIDs-in a cohort of patients with psoriasis. PATIENTS AND METHODS: AQUILES was a prospective observational multicenter study of 3 patient cohorts (patients with psoriasis, spondyloarthritis, or inflammatory bowel disease) undertaken to investigate the prevalence of comorbidities, including other IMIDs, in these settings. The psoriasis cohort comprised patients aged at least 18 years who were seen in hospital dermatology clinics. A predefined protocol was used to collect demographic and clinical data. RESULTS: The study enrolled 528 patients with psoriasis (60.2% men and 39.8% women). Mean age was 46.7 years; 89.8% of the participants had plaque psoriasis, and the median Psoriasis Area Severity Index score (PASI) was 3.2 (1.5-7.4). Comorbid IMIDs were present in 82 (15.5%) of the patients (CI 95%, 12.7%-18.9%). Spondyloarthritis was observed in 14% of patients (95% CI, 11.3%-17.2%), mostly in the form of psoriatic arthritis, for which the overall prevalence was 13.1% (95% CI, 10.5%-16.2%). Inflammatory bowel disease was present in 1.3% (95% CI, 0.6%-2.7%) and uveitis in .2% (95% CI, 0.1%-1.4%). Psoriatic arthritis was associated with male sex (odds ratio, 1.75 [.98-2.98]) and a disease duration of over 8 years (OR, 4.17 [1.84-9.44] vs a duration of < 4 years). In 73.1%, at least 1 cardiovascular risk factor was identified: smoking (40.5%), obesity (26.0%), dyslipidemia (24.8%), hypertension (24.3%), and diabetes mellitus (12.3%). CONCLUSION: In patients with psoriasis the prevalence of other IMIDs was 15.5%, a level slightly higher than that found in the general population. Nearly three-quarters of these patients had at least 1 cardiovascular risk factor.

Do Malassezia species play a role in exacerbation of scalp psoriasis?

INTRODUCTION: Clinical expression of psoriasis is in part dependent on external factors, such as drugs, microorganisms or stress. However convincing evidence of the role of Malassezia species in the pathogenesis of the psoriasis is still lacking. PATIENTS AND METHODS: Samples taken from scalp skin of 40 psoriatic patients and the same number of healthy individuals were observed under direct microsocopic examination and cultured on modified Dixon agar. RESULTS: Direct microscopy examination of psoriatic scalp scales was positive in 30 (75%) patients; while it was positive in only 12 (30%) healthy subjects (P=0.003). Half of the cultures from healthy subjects showed no growth of colonies, but only 8 (15%) of psoriatic patients were negative. When an exacerbation has occurred in the previous weeks, pseudohyphaes were observed in 12 (40%) patients, Malassezia globosa was isolated in 18 (45%) patients and Malassezia restricta was isolated in 12 (30%) patients. In the group of patients having stable lesion, without any exacerbation in the previous weeks, no pseudohypahes were observed, M. globosa was not isolated, M. restricta was isolated in 4 (10%), and cultures were negative in 6 of them (15%). CONCLUSIONS: Malassezia species form an integral part of normal cutaneous microflora in humans, however we found that during the episodes of exacerbation of the disease the presence of these yeasts, and particularly M. globosa, was increased.

Probable primary cutaneous histoplasmosis in a patient infected with HIV.

Histoplasmosis is a fungal infection caused by a dimorphic fungus, Histoplasma capsulatum. Most infections occur after inhalation of fungal spores. A wide variety of clinical manifestations can occur depending on the host response and the extent of inoculation. We report a case of probable cutaneous histoplasmosis after trauma in a 26-year-old man from Paraguay who was also infected with the human immunodeficiency virus. Diagnosis was based on histological and mycological examination. No systemic involvement was found.

[Impact of melanoma diagnosis on sun protection]. / Impacto del diagnóstico de melanoma sobre la fotoprotección.

INTRODUCTION: Knowledge of the dangers of sun exposure does not always lead to changes in behavior. Failure to make behavioral adjustments is of particular concern in high-risk patients. OBJECTIVES: a) To assess the impact of melanoma diagnosis on knowledge, attitudes, and behaviors relating to sun protection, and b) to identify factors that could influence sun protection behaviors. METHODS: A coded, anonymous questionnaire was given to 195 patients with a recent diagnosis of melanoma. Data were collected on clinical and demographic variables and on knowledge, attitudes, and behaviors relating to sun protection before and after diagnosis. The questionnaire also addressed patients' sense of distress and guilt following diagnosis. RESULTS: Sun protection behaviors improved following diagnosis in 66% of patients. Although 98% of patients reported having received advice on sun protection following diagnosis, 15% continued to take inadequate sun protection measures. The probability of behavioral improvement following diagnosis was 4 times greater in women than in men. The subgroup of patients whose behavior improved had worse behaviors prior to diagnosis than did those who showed no improvement. Patients who expressed distress and feelings of guilt following diagnosis were more likely to improve their sun protection behavior. Age, tumor site, intensiveness of treatment, and belief that a suntan is healthy had no significant influence on behavioral change. CONCLUSIONS: Melanoma diagnosis is associated with increased knowledge of sun protection measures and improvement in behaviors. Nevertheless, patients continue to use inadequate sun protection measures. Identification of barriers to optimal sun protection behavior may be instrumental in designing targeted educational campaigns.

Impacto del diagnóstico de melanoma sobre la fotoprotección / Impact of Melanoma Diagnosis on Sun Protection

Introducción: El conocimiento sobre los peligros de la exposición solar no siempre se traduce en cambios en el comportamiento. Esto es particularmente alarmante en pacientes de alto riesgo. Objetivos: a) Evaluar el impacto del diagnóstico de melanoma en los conocimientos, actitudes y hábitos sobre fotoprotección, y b) analizar qué factores pueden influir en el cambio de hábitos de fotoprotección. Métodos: Usando un cuestionario anónimo y codificado que recogía datos clinicodemográficos, 195 pacientes con reciente diagnóstico de melanoma fueron interrogados sobre los conocimientos, hábitos y actitudes sobre fotoprotección antes y después del diagnóstico y sobre los sentimientos de angustia y culpabilidad tras el mismo. Resultados: El 66% de los pacientes optimizó su conducta tras el diagnóstico. Un 15% mantuvo conductas deficientes, a pesar de que el 98% de los sujetos refería haber recibido consejos de fotoprotección tras el diagnóstico. Las mujeres optimizaron su conducta 4 veces más que los hombres. El subgrupo de pacientes que mejoró presentaba conductas más deficientes que el subgrupo que no mejoró. Aquellos que experimentaron sentimientos de angustia y culpa tras el diagnóstico presentaron mayor probabilidad de optimizar su conducta. La edad, la localización tumoral, la agresividad terapéutica y la creencia de que el bronceado es saludable no tuvieron influencia significativa en la modificación de la conducta. Conclusión: El diagnóstico de melanoma lleva consigo un aumento en los conocimientos y un cambio favorable en los hábitos de fotoprotección. A pesar de ello, las medidas de fotoprotección no son lo suficientemente adecuadas. La evaluación de las barreras hacia la fotoprotección óptima puede ser la clave para diseñar programas educacionales específicos (AU)

Introduction: Knowledge of the dangers of sun exposure does not always lead to changes in behavior. Failure to make behavioral adjustments is of particular concern in high-risk patients. Objectives: a) To assess the impact of melanoma diagnosis on knowledge, attitudes, and behaviors relating to sun protection, and b) to identify factors that could influence sun protection behaviors. Methods: A coded, anonymous questionnaire was given to 195 patients with a recent diagnosis of melanoma. Data were collected on clinical and demographic variables and on knowledge, attitudes, and behaviors relating to sun protection before and after diagnosis. The questionnaire also addressed patients’ sense of distress and guilt following diagnosis. Results: Sun protection behaviors improved following diagnosis in 66% of patients. Although 98% of patients reported having received advice on sun protection following diagnosis, 15% continued to take inadequate sun protection measures. The probability of behavioral improvement following diagnosis was 4 times greater in women than in men. The subgroup of patients whose behavior improved had worse behaviors prior to diagnosis than did those who showed no improvement. Patients who expressed distress and feelings of guilt following diagnosis were more likely to improve their sun protection behavior. Age, tumor site, intensiveness of treatment, and belief that a suntan is healthy had no significant influence on behavioral change. Conclusions: Melanoma diagnosis is associated with increased knowledge of sun protection measures and improvement in behaviors. Nevertheless, patients continue to use inadequate sun protection measures. Identification of barriers to optimal sun protection behavior may be instrumental in designing targeted educational campaigns (AU)

Tinea of vellus hair: an indication for systemic antifungal therapy.

BACKGROUND: 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. OBJECTIVES: To present a prospective observational study of 13 cases of tinea of glabrous skin with topical antifungal resistance during the period 2007-2009. METHODS: Cases were analysed from a clinical, mycological and therapeutic standpoint. RESULTS: 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. CONCLUSIONS: 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.

Nódulo ulcerado con lesiones satélites en el pulpejo del primer dedo de un paciente anciano / Ulcerated Nodule With Satellite Lesions on the Pulp of the First Finger of an Elderly Male Patient

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[Pityriasis versicolor and the yeasts of genus Malassezia]. / La pitiriasis versicolor y las levaduras del género Malassezia.

Although pityriasis versicolor is the only human disease for which Malassezia yeasts have been fully established as pathogens, it is still not clear which species are implicated. Most studies carried out in recent years support our hypothesis - proposed in 1999 - that Malassezia globosa is the predominant species in pityriasis versicolor lesions, at least in temperate climates. Confirmation of this hypothesis could help us understand the conditions, as yet unclear, that induce transformation of this yeast from the saprophytic form present in healthy skin to the parasitic form, characterized by the formation of pseudomycelium, and could also guide therapy. In addition, isolation of another species, Malassezia furfur, which seems to be predominant in the tropics, raises the possibility of a second etiologic agent confined to certain areas, as occurs with some other human mycoses.

La pitiriasis versicolor y las levaduras del género Malassezia / Pityriasys versicolor and the yeasts of genus Malassezia

Aunque la pitiriasis versicolor (PV) es la única enfermedad humana en la que el rol etiológico de las levaduras Malassezia está plenamente establecido, permanece como objeto de controversia cuál (o cuáles) es la especie implicada. La mayoría de los estudios llevados a cabo en estos últimos años apoyan nuestra hipótesis, expuesta ya en 1999, indicando que M. globosa es la especie predominante en las lesiones de PV, al menos en los climas templados. La confirmación de esta hipótesis podría ayudar a comprender las condiciones, todavía poco claras, que inducen la transformación de esta levadura de su forma saprofita presente en la piel sana, a la parasitaria, caracterizada por la formación de pseudomicelio, y ayudarían también a establecer las mejores medidas terapéuticas. Por otro lado, el aislamiento de otra especie, M. furfur, que parece predominar en regiones tropicales, podría plantear la posibilidad de un segundo agente etiológico confinado a ciertas áreas geográficas, como acontece en algunas otras micosis humanas (AU)

Although pityriasis versicolor is the only human disease for which Malassezia yeasts have been fully established as pathogens, it is still not clear which species are implicated. Most studies carried out in recent years support our hypothesis —proposed in 1999— that Malassezia globos a is the predominant species in pityriasis versicolor lesions, at least in temperate climates. Confirmation of this hypothesis could help us understand the conditions, as yet unclear, that induce transformation of this yeast from the saprophytic form present in healthy skin to the parasitic form, characterized by the formation of pseudomycelium, and could also guide therapy. In addition, isolation of another species, Malassezia furfur, which seems to be predominant in the tropics, raises the possibility of a second etiologic agent confined to certain areas, as occurs with some other human mycoses (AU)

[Teledermatology. Review of 917 teleconsults]. / Teledermatología. Revisión de 917 teleconsultas.

INTRODUCTION: Teledermatology is been currently introduced as a diagnostic tool in the daily practice of the dermatologist. Many published works regarding teleconsult show the high sensitivity and economic saving of this technique as a diagnostic method. MATERIAL AND METHODS: In this article we report our experience with nearly 1,000 teleconsults carried out in a period of two years, from October 2004 to October 2006. RESULTS: The majority of the 917 teleconsults performed were for benign lesions, notably seborrheic keratosis in 201 cases; among malignant lesions actinic keratosis appeared in 161 cases and melanoma was diagnosed in 5 cases. Fifty-eight percent of teleconsults have been arranged for a face-to-face consult in order to perform adequate treatment, in 90 % of cases, or to confirm diagnosis or carry out complementary exams, in 10 % of cases. CONCLUSION: The image is the gold standard for dermatological diagnosis. Currently, digital phototography gives us such a high image quality that, based on our experience, it can be stated that a neoplastic lesion that cannot be diagnosed by a high quality digital image with the available technology, rarely could be diagnosed in a face-to-face consult without the aid of complementary exams.

Teledermatología. Revisión de 917 teleconsultas / Teledermatology. Review of 917 teleconsults

Introducción. Actualmente el uso de la teledermatología como herramienta diagnóstica está introduciéndose en la práctica diaria del dermatólogo, ya son muchos los trabajos publicados sobre la teleconsulta, donde se demuestra la alta sensibilidad y el alto ahorro económico de esta técnica como método diagnóstico. Material y métodos. Presentamos en este artículo nuestra experiencia con cerca de 1.000 teleconsultas realizadas en un periodo de 2 años, desde octubre de 2004 a octubre de 2006. Resultados. De las 917 teleconsultas realizadas, la mayoría de las lesiones han sido de patología benigna, destacando las queratosis seborreicas en 201 ocasiones, entre la patología maligna destacan las queratosis actínicas en 161 de los casos y se han diagnosticado 5 melanomas. El 58 % de las teleconsultas han sido citados para la consulta de presencia física, ya sea para realizar el tratamiento adecuado, en el 90 % de los casos, como para confirmar el diagnóstico o realizar pruebas complementarias, en un 10%. Conclusión. La imagen es el gold standard para el diagnóstico dermatológico. Actualmente la fotografía digital nos da tal calidad de imagen que, a la luz de nuestra experiencia, cabría afirmar que la patología tumoral que no pueda diagnosticarse con una imagen fotográfica digital de alta calidad, como las que proporcionan los instrumentos y medios que manejamos, raramente pueden llegar a diagnosticarse en presencia física sin la ayuda de pruebas complementarias

Introduction. Teledermatology is been currently introduced as a diagnostic tool in the daily practice of the dermatologist. Many published works regarding teleconsult show the high sensitivity and economic saving of this technique as a diagnostic method. Material and methods. In this article we report our experience with nearly 1,000 teleconsults carried out in a period of two years, from October 2004 to October 2006. Results. The majority of the 917 teleconsults performed were for benign lesions, notably seborrheic keratosis in 201 cases; among malignant lesions actinic keratosis appeared in 161 cases and melanoma was diagnosed in 5 cases. Fifty-eight percent of teleconsults have been arranged for a face-to-face consult in order to perform adequate treatment, in 90 % of cases, or to confirm diagnosis or carry out complementary exams, in 10 % of cases. Conclusion. The image is the gold standard for dermatological diagnosis. Currently, digital phototography gives us such a high image quality that, based on our experience, it can be stated that a neoplastic lesion that cannot be diagnosed by a high quality digital image with the available technology, rarely could be diagnosed in a face-to-face consult without the aid of complementary exams

Aspectos novedosos en la epidemiologíade las micosis superficiales en España / Novel aspects in the epidemiology of superficial mycoses in Spain

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Estado actual de la Micología en la Dermatología en España / Current state of Mycology in the setting of Dermatology in Spain

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Malassezia globosa as the causative agent of pityriasis versicolor.

BACKGROUND: The taxonomic revision carried out in 1996 on the genus Malassezia, which now comprises seven different species, made necessary a re-evaluation of the data concerning the ecology and pathogenicity of these lipophilic yeasts. Very little has been published since then. OBJECTIVES: The aim of this work was to contribute to the knowledge of the aetiology of pityriasis versicolor (PV) with a mycological study made according to the new species. METHODS: Ninety-six patients with PV completed the study. In all of them, samples were taken from the lesions for direct microscopy with KOH+ Parker ink and culture. Samples were also taken from normal skin of the trunk and the forehead of the same patients for culture. Cultures were made in modified Dixon medium in Petri dishes, incubated at 31 degrees C and the isolates were identified by morphological and physiological characteristics. RESULTS: In the PV lesions, direct microscopy always showed the typical mixture of globose blastoconidia and pseudomycelium. Only one patient, having received previous topical antimycotic treatment, was negative. The spherical yeasts observed in vivo were morphologically identical to the globose yeasts characteristic of M. globosa. In culture, M. globosa was found in 97% of cases, alone in 60% of them and associated with M. sympodialis in 29% and M. slooffiae in 7%. These two species were also found in similar percentages on the clinically uninvolved skin of the trunk, whereas M. globosa was not isolated at these sites. However, on the forehead, a small number of colonies of M. globosa was recovered in 12% of cases. CONCLUSIONS: These results support the data previously reported and strongly suggest that M. globosa in its mycelial phase is the causative agent of PV.