CHROMOMYCOSIS ---------------------------------------------- I saw a 52 year old man today who has been attending our clinic since 1991 with chromomycosis which has been resistant to all treatment to date. At the time of presentation in 1991, he gave a 10 year history of a single erythematous scaly plaque on his right knee which was increasing in size. The lesion appeared following a trauma to that region. Skin biopsy confirmed chromomycosis. Culture showed Fonsecaea peduosi. Over the next few years, he was tried on ketoconazole 5 flucytosine liquid nitrogen itraconazole 100 mg - 5 months lamisil 250 mg daily - 3.5 months fluconazole 100 mg daily - 5.5 months potassium iodide 1 drop tds - discontinued after 10 days due to intolerance Repeated skin biopsy in 1994 again showed chromomycosis with similar culture results. He feels well systemically. HIV negative. Any help regarding further management of this case will be greatly appreciated. TC LIM ------ Try Diflucan 200 mg/day plus Lamisil 250 mg/day. Rick Sharpe ----------- A quick review of the recent literature suggest that itraconazole may be the single agent drug of choice for chromoblastomycosis, but it was probably not given for long enough (a year or more probably needed), [1-3] , particularly since chromoblastomycosis due to Fonsecaea peduosi is more difficult to treat [4] . Other things to consider: 1) use fluconzole in combination with itraconazole [4, 5] 2) use hyperthermia as an adjunct to whatever else you are doing [4, 7] . One report from Japan about oral high dose amphotericin B that might be worth checking out [6]. A good recent review might be Restrepo et al, 1994 in the blue journal. Hope this helps. Mark Naylor, M.D. ----------------- I think the suggestion of Itraconazole and terbinafine combination therapy is intriguing. For the past several years I have been impressed by the clinical results in my chronic tinea pedis patients when treated with concurrent topical Naftifine and oxiconazole or econazole. I prescribe these to be applied alternately AM & PM daily for 8 weeks. Usually this clears the skin completely and the improvement seems to last. My rationale is that the two drugs inhibit the ergosterol biosynthetic pathway at two different, sequential points, perhaps providing therapeutic synergy analogous to the folate pathway inhibition of trimethoprim&sulfamethoxazole. If it works topically, why not try it systemically? Gene Sienkiewicz, M. D. ----------------------- The dose of 100mg per day of itraconazole may not have been adequate. I beleive the recommended dose is 200 to 400mg/d for 6-12 mos. Charles Fishman, M.D. ---------------------- Just a reminder to give itraconzole with an acidic drink and a meal, per Dr. Paul Jacobs, as it will not be well enough absorbed. Diane Thaler ------------ Regarding concurrent use of topical anti-fungal agents when such agents work at different sites in the ergosterol pathway. I have been doing the same for a long while in those cases that are severe, or chronic. I don't have any hard data, but I agree the results seem to be better then when one agent alone is used. Elliot Puritz ------------- I have seen chromomycosis respond to topical heat therapy. For a reference see JAAD 1984;10:615. Jason Rivers ------------ I have seen a similar case of chromomycosis on the back, present for over 20 years. Aggressive efforts to eradicate the plaque have not been successful. It is causing no systemic symptoms, seems to enlarge gradually, and causes no untoward effects. Our plan has been topical antifungals and an attitude of tolerance. Barbara R. Reed, MD -------------------