Dermorama

Fungal infection of the beard area (tinea barbae) should be considered when inflammation occurs in this area. Bacterial folliculitis and inflammation secondary to ingrown hairs (pseudofolliculitis) are common. However, it is not unusual to see patients who have finally been diagnosed as having tinea after failing to respond to several courses of antibiotics. A positive culture for staphylococcus does not rule out tinea, in which purulent lesions may be infected secondarily with bacteria. Like tinea capitis, the hairs are almost always infected and easily removed. The hairs in bacterial folliculitis resist removal.

This pattern clinically resembles bacterial folliculitis except that it is slower to evolve and is usually restricted to one area of the beard. Bacterial folliculitis spreads rapidly over wide areas after shaving. Tinea begins insidiously with a small group of follicular pustules. The process becomes confluent in time with the development of a boggy, erythematous, tumorlike abscess covered with dense, superficial crust similar to fungal kerions seen in tinea capitis. Hairs may be painlessly removed at almost any stage of the infection and examined for hyphae. Zoophilic T. mentagrophytes and T. verrucosum are the most common pathogens. Species identification by culture helps to identify the possible animal reservoir of infection.

Griseofulvin is active only against dermatophytes; yeast infections, including those caused by Candida organisms and Pityrosporum organisms (tinea versicolor), and deep fungi do not respond. The drug has been available for more than 20 years and has been proven safe. Griseofulvin has a fungistatic effect, therefore it works best on actively growing dermatophytes in which it may inhibit fungal cell-wall synthesis. Griseofulvin probably diffuses into the stratum corneum from the extracellular fluid and sweat. Increased sweating may increase the concentration in the stratum corneum, thereby enhancing the drug's effect. Griseofulvin produces a sustained blood level so that a once- or twice-a-day schedule is adequate. Absorption varies from person to person; individual patients attain consistently high or low levels of the drug. Taking the drug with fatty foods may enhance absorption.

Two preparations are available: microsize and ultramicrosize. The newer, ultramicrosized forms are better absorbed and require approximately 50% to 70% of the dosage of the microsized form. Many brands are available in both forms. In microsize, the drug is supplied as 125-mg, 250-mg, and 500-mg tablets; in ultramicrosize, it is supplied as 125-mg, 250-mg, and 330-mg tablets. The recommended dosage and duration of therapy are listed in Table 13-2 . The dosage should be adequate. Reported treatment failures are probably the result of using too small a dosage rather than resistant organisms.

	Griseofulvin	Ketoconazole (Nizoral)	Fluconazole (Diflucan)	Itraconazole (Sporanox)	Terbinafine (Lamisil)
Dosage forms	125, 250, 333 mg ultramicronized tablet 125 mg/5 ml food enhances absorption	200 mg tablet taken with breakfast with an acidic fruit juice	50, 100, 200 mg tablets Water soluble, well absorbed	100 mg capsule food enhances absorption^[23]	250 mg
Fungicidal	No	No	No	No	Yes
Persistent in plasma after Rx	2 weeks	2 days	--	1 week	4 to 6 weeks
Persistent in skin and nails after Rx	1 to 2 weeks	Unknown	3 months	6 to 9 months	4 to 6 weeks
Laboratory monitoring	Rx 6 weeks com- plete blood count (CBC) liver func- tion test (LFT)	Baseline CBC, LFT; repeat each month	Baseline CBC, LFT; repeat each month	Baseline CBC, LFT; repeat each month	CBC, repeat each month
Adverse reactions	8% to 15%	13%	7%	7%	5%
Safety profile	Multiple uncom- mon side effects	Fulminant hepato- toxicity in 1/10,000	Less hepatotoxicity than ketocon- azole	Less hepatotoxicity than ketocon- azole	Few side effects; minor GI distur- bances
Adverse reactions	Abdominal pain, erythema multiforme, headache, mixed drug reactions, nausea and vomiting, photosensitivity, urticaria	Abdominal pain, nausea and vomiting, dizziness, fever, headache, pruritus, inhibition of testicular and adrenal steroido- genesis	Abdominal pain, nausea and vomiting, headache, rash	Nausea and vomiting, abdominal pain, hypokalemia, increased aminotransferase activity, dizziness, headache, pruritus, rash, sleepiness	Nausea and vomiting, abdominal pain, dizziness, headache, pruritus, rash, taste loss
Potential drug interaction	Alcohol, barbiturates, coumarin, oral contraceptives, warfarin	Alcohol, antacids, astemizole, coumarin, cyclosporine, erythromycin, H₂ antagonists, isoniazid, phenytoin, rifampin, sulfonylureas, terfenadine	Coumarin, cyclosporine, hydrochlorothiazids, isoniazid, oral contraceptives, phenytoin, rifampin, sulfonylureas, valproic acid	Astemizole, carbamazepine, coumarin, cyclosporine, digoxin, erythromycin, H₂ antagonists, isoniazid, phenobarbital, phenytoin, rifampin, sulfonylureas, terfenadine	H₂ antagonists, rifampin, cyclosporine
Cost to pharmacist/pill	$90/100 pills	$232/100 pills	$173/30 pills (100 mg)	$139/30 pills	Available in 1995 or 1996 in the United States

The patient euthanized his cat last week. Was this necessary? Yes

Does he need referral to a dermatologist? No

How are you going to code the visit? Carefully, to five digits, with the appropriate code.