[Requirements for mycological diagnostics in accordance with the guideline of the German Medical Association for quality assurance of medical laboratory tests]. / Anforderungen für die mykologische Diagnostik entsprechend der Richtlinie der Bundesärztekammer (Rili-BÄK) zur Qualitätssicherung laboratoriumsmedizinischer Untersuchungen.

The ability of recognizing various clinical manifestations of mucocutaneous mycosis, making a diagnosis, and establishing a treatment is part of a dermatologist's daily routine. However, due to the fact that clinical manifestations, laboratory diagnostics, and treatment are performed in one hand, laboratory findings are properly classified and interpreted. Since new binding guidelines of the German Medical Association on quality assurance measures in medical laboratory testing came into force, there is much concern among dermatologists of how to comply with these new regulations. It is the intention of the authors to help our readers to implement these new rules in order to make sure that mycological diagnostics continue to be part of a dermatologist's professional work.

[Tropical and travel-related dermatomycoses : Part 2: cutaneous infections due to yeasts, moulds, and dimorphic fungi]. / Tropen- und Reise-assoziierte Dermatomykosen : Teil 2: Kutane Infektionen durch Hefepilze, Schimmelpilze und dimorphe Pilze.

Besides dermatophytoses, a broad range of cutaneous infections due to yeasts and moulds may occur in subtropical and tropical countries where they can affect travellers. Not to be forgotten are endemic occurring dimorphic or biphasic fungi in countries with hot climate, which cause systemic and secondary cutaneous infections in immunosuppressed and immunocompetent people. In the tropics, the prevalence of pityriasis versicolor, caused by the lipophilic yeast Malassezia spp., is about 30-40 %, in distinct areas even 50 %. Increased hyperhidrosis under tropical conditions and simultaneously humidity congestion have to be considered as significant disposing factors for pityriasis versicolor. In tropical countries, therefore, an exacerbation of a preexisting pityriasis versicolor in travellers is not rare. Today, mostly genital yeast infections due to the new species Candida africana can be found worldwide. Due to migration from Africa this yeast pathogen has reached Germany and Europe. Eumycetomas due to mould fungi are rarely diagnosed in Europe. These deep cutaneous mould infections are only found in immigrants from African countries. The therapy of eumycetoma is protracted and often not successful. Cutaneous cryptococcoses due to the yeast species Cryptococcus neoformans and Cryptococcus gattii occur worldwide; however, they are found more frequently in the tropics. Immunosuppressed patients, especially those with HIV/AIDS, are affected by cryptococcoses. Furthermore, Cryptococcus gattii also causes infections in immunocompetent hosts in Central Africa, Australia, California, and Central America.Rarely found are infections due to dimorphic fungi after travel to countries where these fungal pathogens are endemic. In individual cases, cutaneous or lymphogenic transferred sporotrichosis due to Sporothrix schenkii can occur. Furthermore, scarcely known is secondary cutaneous coccidioidomycosis due to Coccidioides immitis after travelling to desert-like endemic regions in southwestern states of the United States and in Latin America, where primary respiratory infection due to this biphasic fungus can be acquired. The antifungal agent itraconazole is the treatment of choice for sporotrichosis and coccidioidomycosis. Talaromyces marneffei-until recently known as Penicillium marneffei-is only found in Southeastern Asia. Mycosis due to this dimorphic fungus has to be considered as an AIDS-defining opportunistic infection. After hematogeneous spread, Talaromyces marneffei affects the skin and mucous membranes of the mouth. Amphotericin B and itraconazole can be used for therapy.

[Tropical and travel-related dermatomycoses: Part 1: Dermatophytoses]. / Tropen- und Reise-assoziierte Dermatomykosen : Teil 1: Dermatophytosen.

Today, tropical and travel-related dermatomycoses must be increasingly anticipated to present in dermatological offices and clinics. Skin infections due to dermatophytes or other fungi may occur after a journey in countries with a high prevalence for the respective causative fungal pathogen, e.g., tinea corporis due to Trichophyton soudanense. Otherwise, more frequently, single infections and even localized outbreaks due to "exotic" or "imported" pathogens of dermatophytoses occur. These epidemics are observed in childcare facilities in Germany and in other European countries. Source of infection are immigrants from Africa and sometimes from Asian countries. Furthermore, African children, and sometimes also adults, are often only asymptomatic carriers of such anthropophilic dermatophytes. Outbreaks of dermatophyte infections with one and more affected children and also adult staff and teachers due to Trichophyton violaceum or Microsporum audouinii in kindergartens and schools are not a rarity these days. Further tropical and travel-associated dermatophytes are Trichophyton tonsurans, Trichophyton schoenleinii, and Trichophyton concentricum. Tinea capitis should be treated in a species-specific manner. Griseofulvin is the treatment of choice for infections due to Microsporum species. In contrast, tinea capitis due to Trichophyton species has to be treated by terbinafine, however, because the agent is not approved for children in Germany, only after receiving written consent of parents. Alternatives are fluconazole and itraconazole. Onset and aggravation of tinea pedis during travel has its origin in a preexisting neglected fungal infection of the feet. In the tropics, exacerbations and secondary bacterial complications of tinea pedis develop under distinctly promoting conditions.

Eumycetoma and actinomycetoma--an update on causative agents, epidemiology, pathogenesis, diagnostics and therapy.

Mycetoma is a chronic putrid infection of the cutaneous and subcutaneous tissue concerning predominantly the feet, and more rarely other body parts. Mycetoma can be caused by both fungi (eumycetoma) and bacteria (actinomycetoma). Mode of infection is an inoculation of the causative microorganism via small injuries of the skin. The clinical correlate of both forms of mycetoma is tumescence with abscesses, painless nodules, sinuses and discharge. The latter is commonly serous-purulent and contains grains (filamentous granules) which can be expressed for diagnostic purposes. Distinctive for both eumycetoma and actinomycetoma, are the formation of grains. Grains represent microcolonies of the microorganism in vivo in the vital tissue. The most successful treatment option for eumycetomas offers itraconazole in a dosage of 200 mg twice daily. This triazole antifungal is considered as 'gold standard' for eumycetomas. Alternatively, the cheaper ketoconazole was widely used, however, it was currently stopped by the FDA. Actinomycetomas should be treated by the combination of trimethoprim-sulphamethoxazole (co-trimoxazole 80/400 to 160/800 mg per day) and amikacin 15 mg/kg body weight per day. Mycetomas are neglected infections of the poor. They are more than a medical challenge. In rural areas of Africa, Asia and South America mycetomas lead to socio-economic consequences involving the affected patients, their families and the society in general.

[Certificate "Tropical and Travel Dermatology (DDA)": quality-assured medical education for dermatologists with a "migration perspective"]. / Das Zertifikat "Tropen- und Reisedermatologie (DDA)" : Qualitätsgesicherte Fortbildung für Hautärzte mit "Migrationsperspektive"

Under the conditions of economic pressure in the medical system and the DRG system for hospitals in Germany, so-called "uneconomic" services and fields of specialized dermatologic competence such as pediatric dermatology, trichology, occupational dermatology and tropical dermatology are increasingly being neglected. While hospitals tend to train fewer residents in these subspecialties, there is a demand for additional high-quality training opportunities that are certified by the German Dermatologic Academy (DDA). Tropical and travel-related skin diseases are more frequently observed in Germany which can be explained by the increased world-wide travel activities, but also by the international migration from developing countries into Europe. Furthermore, dermatologists trained in Germany are working more and more also internationally. Thus, they require knowledge and experience in tropical and travel-related dermatology. The certificate "Tropical and Travel Dermatology (DDA)" was developed and published in 2013 in a cooperation between the International Society for Dermatology in the Tropics in cooperation with the German Academy of Dermatology (DDA). It consists of 3 full day teaching modules (basic, additional and special seminar). The first seminar cycle in 2013/2014 showed a high demand from dermatologists in hospitals and private practices. While the basic and the special seminars were held in Germany, the additional seminar took place in cooperation with the Regional Dermatology Training Center (RDTC) in Moshi, Tanzania. Many attending dermatologists fulfilling the requirements for the new certificate have practiced in developing countries or plan to do so. In order to gain practical experience on the basis of the knowledge acquired in the qualifying seminars, the International Society for Dermatology in the Tropics supports dermatologists to find internships and work placements in dermatological units in developing countries.

[Vacation and tropical dermatoses]. / Urlaubs- und Tropendermatosen.

Besides fever and diarrhea, skin diseases are the third most common cause of morbidity in returning travelers after a stay in a tropical country. Approximately one- quarter of these dermatological symptoms can be referred to a classical tropical disease. The majority are of infectious origin. Often only the clinical appearance leads to the diagnosis of a tropical disease as myiasis, cutaneous larva migrans, tungiasis or cutaneous leishmaniasis. Not infrequently the dermatological symptoms lead to the diagnosis of a primarily systemic tropical disease. For example, an eschar with or without a rash might lead to the diagnosis of a South African tick bite fever caused by Rickettsia africae days before serology may turn positive. Less common tropical skin diseases such as lymphatic filariasis and loiasis need to be considered in returning long-term travelers and immigrants.

[Onychomycosis]. / Onychomykose.

Onychomycosis is an infection of the finger-and/or toenails by fungal microorganisms. If untreated, the process advances and destroys the nail plate. It may spread to involve the skin and does not heal spontaneously. There are different clinical presentations of onychomycosis which vary with the nature of the fungus and how it invades the nail unit. These different clinical forms require different therapeutic approaches. The successful treatment of onychomycosis requires special knowledge of the various clinical presentations, of the differential diagnosis and of recent advances in medical mycology. Therefore onychomycosis is best treated by dermatologists.

[Sucessful treatment with clofazimine and itraconazole in a 46 year old patient after 32 years duration of disease]. / Erfolgreiche Therapie mit Clofazimin und Itrakonazol bei einem 46-jährigen Patienten nach 32-jähriger Krankheitsdauer.

Lobomycosis, caused by the fungal pathogen Lacazia loboi, is a chronic deep mycosis and is only found in Central and South America. Clinically the disease is characterized by shiny keloidal nodules appearing mainly on the exposed parts such as face and the upper and lower extremities. Therapeutically the surgical removal of the lesions is considered as the only successful treatment. We describe the therapeutic response of a patient with Lobo's disease treated for one year with a combination of clofazimine (100 mg/day) and itraconazole (100 mg/day). A complete clinical and histopathological remission of the disease was observed. The patient has been followed for three years.

Amorolfine spray in the treatment of foot mycoses (a dose-finding study).

A total of 382 patients with foot mycosis were entered into a dose-finding study. Patients were randomly treated with amorolfine spray 0.5% or 2% (double-blind) or cream 0.5% (open; used as a reference agent). The spray or cream was applied once daily for 4 weeks on average. At screening, in 348 patients evaluable for efficacy, a total of 381 fungi were isolated: Trichopyton rubrum (196), T. mentagrophytes (73), other dermatophytes (17), Candida albicans (65), other yeasts (23), and moulds (7). In 33 patients the fungal infection was mixed. Two weeks after the end of treatment, the culture was negative in 94.1% and 97.4% of patients treated with 0.5% or 2% amorolfine spray, respectively. The difference was not statistically significant. In the 0.5% cream group the culture was negative in 86.6% of patients. Nine out of 380 patients evaluable for safety had local adverse events: four (3.2%) in each of the spray groups, and one (0.8%) in the cream group. The most common local adverse events in the patients treated with spray were a burning sensation and dryness of the skin. In conclusion, both spray concentrations were highly efficacious and well tolerated. Further studies should show if more widely spaced treatment with amorolfine spray is as effective as daily administration.

Comparative efficacy and safety of amorolfine nail lacquer 5% in onychomycosis, once-weekly versus twice-weekly.

Amorolfine is a new topical antifungal of the phenylpropyl morpholine class which is highly active both in vitro and in vivo against yeasts, dermatophytes and moulds responsible for superficial fungal infections. Human pharmacological studies have established that amorolfine has a persistent antifungal effect in the nail bed and in the skin without being systemically absorbed. This has been confirmed by clinical work showing that amorolfine is effective in treating dermatomycoses and onychomycoses when administered as cream or nail lacquer. It is ineffective when given orally for systemic mycoses or bacterial infections in animals. In earlier studies a 5% concentration of amorolfine nail lacquer was found to produce a better cure rate in onychomycosis than a lower concentration of 2%. From data available on the penetration of amorolfine and on the persistence of mycologically relevant tissue concentrations, it appeared likely that once- or twice-weekly application of nail lacquer should suffice to produce a satisfactory therapeutic effect in onychomycosis. The aim of this investigation was to assess the efficacy and tolerability of 5% amorolfine nail lacquer given once versus twice weekly to patients with onychomycosis of finger nails and toe nails.

Topical treatment of onychomycosis with amorolfine 5% nail lacquer: comparative efficacy and tolerability of once and twice weekly use.

456 patients with onychomycosis were treated once or twice weekly for up to 6 months with amorolfine 5% nail lacquer in an open, randomized study. The patients were examined at monthly intervals during treatment and followed-up 1 and 3 months after completion of treatment. Slightly better cure rates were achieved with twice weekly use than with once weekly use (overall cure rates 54.2 vs. 46.0%, p = 0.4). An overall cure or improvement was achieved in 74 and 68% of patients receiving twice- and once-weekly treatment, respectively. The mycological cure rate was 76.1% for twice-weekly treatment and 70.6% for once-weekly treatment. The nail lacquer was extremely well tolerated; 4 out of 456 patients reported mild local irritation. Plasma levels of amorolfine were determined in 19 patients and found to be below the detection limit of 0.5 ng/ml in all cases.

[Fungal involvement of the tongue and feces in dialysis-dependent patients]. / Hefepilzbefall von Zunge und Faeces bei dialysepflichtigen Patienten.

38 patients regularly receiving dialysis and 3 patients with a renal transplant were investigated with regard to possible colonization of yeasts. The tongue and stool were directly examined with Kimmig agar, the resulting yeasts were then differentiated by means of rice agar and an auxanogram. Candida albicans was the germ most frequently found both on the tongue (47.5%) and in the stool (50%). We discuss the significance of our results.

Studies on the yeast flora in patients suffering from psoriasis capillitii or seborrhoic dermatitis of the scalp.

In 65 patients with scalp psoriasis or seborrhoic dermatitis of the scalp, stool specimens, tongue swabs and scalp scales were examined for yeasts. The stool specimens showed in 70.8% of the patient group massive and in 7.7% moderate yeast colonization. Yeasts were found in 47.7% of the tongue cultures and in 12.5% of the scalp scales. Candida albicans was the predominant pathogen in the faeces and on the tongue. In comparison with a control group, frequency of yeasts in faeces and on the tongue in patients with psoriasis capillitii and seborrhoic dermatitis of the scalp could be shown to be significantly higher.

Comparison of efficacy and tolerability of terfenadine administered once daily versus twice daily in patients with chronic idiopathic urticaria.

The objective of this double-blind study, which is part of a multicenter study, was to determine whether terfenadine (120 mg once daily) has similar efficacy and tolerability to the standard dosage of 60 mg twice daily in the treatment of chronic urticaria. Forty-one patients were randomly allocated to two parallel groups and treated for 2 weeks with either regimen. Evaluation of efficacy was based on rating scales for investigator and patient. Primary endpoints were itch, number of wheals, wheal size, and the overall rating of efficacy. A similar improvement was seen in all variables. There were no statistically significant differences between groups. Both treatments were well tolerated.

[Onychomycoses]. / Onychomykosen.

Despite the fact, that onychomycosis is a slow process, patients seek medical assistance normally late, that means in a clinical advanced stage. This is the reason for a prolonged curing-time. The different clinical patterns of onychomycoses and the leading pathogens are represented. Systemic and local therapeutic approaches are discussed. A simple method for the documentation of the curing-process is proposed.