Effective Treatment of Erythrasmaassociated Inflammation and Pruritus with Isoconazole Nitrate and Diflucortolone Valerate Combi

mycoses Diagnosis,Therapy and Prophylaxis of Fungal Diseases

Case report

Effective treatment of erythrasma-associated inﬂammation and pruritus with isoconazole nitrate and diﬂucortolone valerate combination therapy

Malagoli Piergiorgio Istituto Clinico San Siro, Milan, Italy

Summary A warm and moist environment is a common risk factor for erythrasma, a condition characterized by pruritic, scaly and erythematous tan patches on the skin. Here we report on a 13-year-old athletic student presenting with pruritus and mild burning on her left medial thigh, and subsequently diagnosed with erythrasma. The patient was successfully treated with a 5-day regimen of Travocort cream containing isoconazole nitrate 1% and diﬂucortolone valerate 0.1%.

Key words: Erythrasma, Travocort, pruritus, isoconazole nitrate, diﬂucortolone valerate

Introduction Patient presentation and history Erythrasma is a relatively frequent condition that A 13-year-old Caucasian athletic female student without occurs more often during the summer and is more any concomitant diseases presented with pruritus and common in certain patient subsets (e.g., the elderly, mild burning on her left medial thigh. The condition had obese patients and individuals with diabetes mell- been ongoing for the previous 3 weeks (Fig. 1). itus).1 A warm and moist environment, often the result of wearing occlusive clothing, is a common risk factor Clinical examination for erythrasma.2,3 This condition can present as asymptomatic or pruritic, scaly and erythematous tan Upon microscopic examination, it was noted that the patches on the skin, especially at intertriginous patient’s lesions had defined edges that were character- sites.1,4 Well-circumscribed, red–brown plaques and ised by distinct interruption. The upper and outermost patches are typically present. Corynebacterium minu- parts of the lesions were erythematous with fine scales. tissimum, the causative agent of erythramsa, is pri- marily found in occluded intertriginous areas such as Diagnosis the axillae, infra-mammary areas, interspaces of the toes, intergluteal and inguinal folds. This organism is Erythrasma. commonly mistaken for a mycotic infection and, in fact, can be isolated from the skin in mixed infections with Treatment and follow-up dermatophytes or Candida species.5,6 Twice-daily application of cream containing isoconazole nitrate (ISN) and diflucortolone valerate (Travocortâ cream; Intendis GmbH, Berlin, Germany) was prescribed Correspondence: M. Piergiorgio, Istituto Clinico San Siro, Via Monreale, for 7 days. However, treatment was carried out for 5 days. 18, Milan 20148, Italy. Tel.: +39 02 48785233. E-mail: [email protected] Disease course

Submitted for publication 21 December 2012 After 48 h of treatment, there was a marked improve- Accepted for publication 29 December 2012 ment of pruritus and, by the end of the 5-day treatment,

the patient to return to normal daily activities, including athletics. If erythrasma is correctly diagnosed, it is relatively simple to treat.6 Multiple options are available for man- aging erythrasma, including oral and topical therapies. When erythrasma presents in skin folds, topical solu- tions of erythromycin, clindamycin, imidazole derivatives, sodium fusidate ointment and other antibacterials are indicated.1,7–9 ISN is an imidazole antifungal agent and, along with the corticosteroid diflucortolone valerate, is the active ingredient in the topical drug Travo- cort. ISN has a broad spectrum of antimicrobial activity against dermatophytes, pathogenic yeasts, filamentous fungi, moulds, gram-positive bacteria and the causative organisms of erythrasma.10–12 Indeed, ISN was effective Figure 1 Appearance of an erythematous and pruritic erythras- in treating erythrasma in several previous clinical stud- ma lesion on the left medial thigh of a 13-year-old girl prior to 13 treatment. ies. Furthermore, because Travocort contains a corticosteroid, there is rapid relief of the inflammatory aspect of erythrasma, thereby protecting the skin bar- rier from further damage from pruritus-induced scratching.14 In our patient, treatment with Travocort led to high patient satisfaction and increased compliance with the treatment regimen, suggesting that it is an effective therapy in patients with erythrasma accom- panied by inflammatory or eczematous skin conditions.

Acknowledgments The preparation of this manuscript was supported by Intendis GmbH. The author would like to thank Dr Kammy Fehrenbacher for medical writing support, which was funded by Intendis GmbH.

Conflicts of interest Dr Piergiorgio has declared no conflicts of interest. Figure 2 Complete remission of erythrasma lesion after 5 days of twice-daily treatment with Travocort cream. References there was a complete remission of the lesions (Fig. 2). 1 Blaise G, Nikkels AF, Hermanns-Le T, Nikkels-Tassoudji N, The patient had no side effects from the Travocort Pierard GE. Corynebacterium-associated skin infections. Int J cream and found the treatment easy to apply, resulting Dermatol 2008; 47: 884–90. in a high compliance to the prescribed regimen. 2 Golledge CL, Phillips G. Corynebacterium minutissimum infection. J Infect 1991; 23:73–6. 3 Hartmann AA. The influence of various factors on the Discussion human resident skin flora. Semin Dermatol 1990; 9: 305–8. In the case of this patient, the erythrasma proliferated 4 Hodson SB, Henslee TM, Tachibana DK, Harvey CK. Inter- in the inner medial thigh because of intense physical digital erythrasma. Part I: A review of the literature. JAm Podiatr Med Assoc 1988; 78: 551–8. activity. The pruritus and burning limited the patient’s 5 Allen S, Christmas TI, McKinney W, Parr D, Oliver GF. The daily activities. The use of a treatment regimen with a Auckland skin clinic tinea pedis and erythrasma study. NZ rapidly effective and safe profile provided complete res- Med J 1990; 103: 391–3. olution of the dermatological condition and allowed

6 Holdiness MR. Management of cutaneous erythrasma. Drugs derivatives (author’s transl)]. Arzneimittelforschung 1979; 2002; 62: 1131–41. 29: 1344–51. 7 Wilkinson JD. Fusidic acid in dermatology. Br J Dermatol 12 Oyeka CA, Gugnani HC. In vitro activity of seven azole com- 1998; 139(Suppl. 53): 37–40. pounds against some clinical isolates of non-dermatophytic 8 Spelman D. Fusidic acid in skin and soft tissue infections. filamentous fungi and some dermatophytes. Mycopathologia Int J Antimicrob Agents 1999; 12(Suppl. 2): S59–66. 1990; 110: 157–61. 9 Hamann K, Thorn P. Systemic or local treatment of erythrasma? 13 Weitgasser H, Herms E. [Comparative clinical investigations A comparison between erythromycin tablets and Fucidin cream with the new antimycotic agent isoconazole nitrate and its in general practice. Scand J Prim Health Care 1991; 9:35–9. combination with diflucortolone-21-valerate in the case of 10 Czaika V, Siebenbrock J, Friedrich M, Czekalla F, Nußlein€ B, inflammatory and eczematised dermatomycoses]. Mykosen Sieber MA. Bacteriostatic and bacteriocidial effects of isoconazole 1979; 22: 177–83. nitrate. Lisbon, Portugal: EADV, 2011. Abstract and Poster 14 Gip L, Langen ML. [Results of a contralateral comparative PO158. study between Travocort cream and Travogen cream in 11 Kessler HJ. [Microbiological studies on isoconazole nitrate, a inflammatory and allergic dermatomycoses (author’s broad spectrum antimycotic from the series of imidazole transl)]. Mykosen 1980; 23:79–84.

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