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The choice of treatment is generally guided by clinical&#44; mycologic&#44; and histopathologic criteria&#46; We describe a case of imported chromoblastomycosis&#44; a disease rarely seen in Spain&#44; that had been present for many years and was resolved with combination therapy&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 50-year-old construction worker from Brazil who had been living in Catalonia&#44; Spain for a year&#46; He had a history of hypertension and presented with mildly pruritic and occasionally painful lesions on the arm and elbow that had been present for 20 years&#46; The lesions had grown progressively and centrifugally and had never completely healed&#46; The patient recalled having been injured with a nail before the lesions appeared&#46; He had attempted treatment with several topical antifungal drugs&#44; with no improvement&#46; He was not on any regular medication&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Physical examination revealed indurated&#44; erythematous&#44; contiguous plaques with warty&#44; crusted areas&#59; adjacent to these plaques was a larger whitish area with a scar-like appearance &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The regional lymph nodes were not palpable&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Laboratory tests&#44; including a complete blood count with white blood cell count&#44; basic biochemical tests&#44; liver function tests&#44; and coagulation tests&#44; showed no abnormalities&#46; The erythrocyte sedimentation rate was normal&#46; Histology showed pseudoepitheliomatous epidermal hyperplasia and an intense inflammatory granulomatous reaction throughout the dermis with epithelioid cells&#44; giant multinucleated cells&#44; plasma cells&#44; neutrophils&#44; and occasional microabscesses&#46; The dermis and microabscesses contained small &#40;5-15<span class="elsevierStyleHsp" style=""></span>&#956;m&#41; pigmented spores with a thick wall and in some cases central septation &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Periodic-acid Schiff and methenamine silver stains were positive&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Bacterial and fungal cultures of biopsy specimens yielded several colonies of <span class="elsevierStyleItalic">Stenotrophomonas maltophilia</span> and <span class="elsevierStyleItalic">F pedrosoi</span>&#44; respectively&#46; The mycobacterial culture was negative&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Based on the above results&#44; we established a definitive diagnosis of cutaneous chromoblastomycosis&#46; Topical antibiotics were administered to treat the secondary bacterial infection and the lesions were treated by curettage&#46; The patient was also prescribed terbinafine &#40;500<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#41; and 1 month later underwent the first of 2 cryotherapy sessions separated by an interval of 2 months&#46; Treatment with terbinafine was maintained for 6 months&#44; with a progressive reduction in doses&#46; The lesions healed&#44; leaving residual scarring &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; and no recurrences were observed during the 24-month follow-up period&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Chromoblastomycosis is difficult to treat because of differences in antifungal sensitivity patterns and responses among the species isolated and also because of the refractory nature of the condition&#44; particularly in more serious clinical forms&#46;The different treatment modalities available have not been compared in clinical settings&#46; Recurrence is common&#44; hence the recommendation for long-term treatments&#44; lasting between 3 and 18 months&#44; depending on the study&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Possible complications include secondary bacterial infection with lymphadenitis and&#44; less frequently&#44; the development of squamous carcinoma in lesions that have been present for a very long time&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In our case&#44; the only complication was secondary impetiginization&#44; which was resolved with topical antibiotics&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Treatments can be divided into 3 broad modalities&#58; physical treatments&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> pharmacologic treatments&#44; and combined therapies&#46; Surgery may be the best choice in the early stages of disease&#44; but systemic antifungals are necessary in more advanced cases&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">A variety of treatment regimens have been attempted&#44; but it is impossible to determine the best option due to a lack of comparative clinical studies using objective criteria&#46; The best systemic antifungals seem to be itraconazole and terbinafine because of their spectrum of action and safety in long-term regimens&#46; However&#44; tissue fibrosis secondary to infection can reduce drug tissue levels&#46; Terbinafine may have antifibrotic properties that would favor the healing of chromoblastomycosis lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Terbinafine combined with cryotherapy has emerged as a possible treatment option in recent years&#46; Of all the physical treatments described in the literature&#44; cryotherapy is associated with the best outcomes&#44; with a cure rate of 40&#46;9&#37; when used as monotherapy&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Moreover&#44; it appears to be particularly useful when combined with systemic antifungals to treat long-standing lesions that are not candidates for surgery&#46; 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Case and Research Letter
Chromoblastomycosis: Response to Combination Therapy With Cryotherapy and Terbinafine
Cromomicosis. Respuesta al tratamiento combinado con crioterapia y terbinafina
J. Bassas-Vila
Corresponding author
julibassas@gmail.com

Corresponding author.
, M.J. Fuente, R. Guinovart, C. Ferrándiz
Servei de Dermatologia, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
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The choice of treatment is generally guided by clinical&#44; mycologic&#44; and histopathologic criteria&#46; We describe a case of imported chromoblastomycosis&#44; a disease rarely seen in Spain&#44; that had been present for many years and was resolved with combination therapy&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 50-year-old construction worker from Brazil who had been living in Catalonia&#44; Spain for a year&#46; He had a history of hypertension and presented with mildly pruritic and occasionally painful lesions on the arm and elbow that had been present for 20 years&#46; The lesions had grown progressively and centrifugally and had never completely healed&#46; The patient recalled having been injured with a nail before the lesions appeared&#46; He had attempted treatment with several topical antifungal drugs&#44; with no improvement&#46; He was not on any regular medication&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Physical examination revealed indurated&#44; erythematous&#44; contiguous plaques with warty&#44; crusted areas&#59; adjacent to these plaques was a larger whitish area with a scar-like appearance &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The regional lymph nodes were not palpable&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Laboratory tests&#44; including a complete blood count with white blood cell count&#44; basic biochemical tests&#44; liver function tests&#44; and coagulation tests&#44; showed no abnormalities&#46; The erythrocyte sedimentation rate was normal&#46; Histology showed pseudoepitheliomatous epidermal hyperplasia and an intense inflammatory granulomatous reaction throughout the dermis with epithelioid cells&#44; giant multinucleated cells&#44; plasma cells&#44; neutrophils&#44; and occasional microabscesses&#46; The dermis and microabscesses contained small &#40;5-15<span class="elsevierStyleHsp" style=""></span>&#956;m&#41; pigmented spores with a thick wall and in some cases central septation &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Periodic-acid Schiff and methenamine silver stains were positive&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Bacterial and fungal cultures of biopsy specimens yielded several colonies of <span class="elsevierStyleItalic">Stenotrophomonas maltophilia</span> and <span class="elsevierStyleItalic">F pedrosoi</span>&#44; respectively&#46; The mycobacterial culture was negative&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Based on the above results&#44; we established a definitive diagnosis of cutaneous chromoblastomycosis&#46; Topical antibiotics were administered to treat the secondary bacterial infection and the lesions were treated by curettage&#46; The patient was also prescribed terbinafine &#40;500<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#41; and 1 month later underwent the first of 2 cryotherapy sessions separated by an interval of 2 months&#46; Treatment with terbinafine was maintained for 6 months&#44; with a progressive reduction in doses&#46; The lesions healed&#44; leaving residual scarring &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; and no recurrences were observed during the 24-month follow-up period&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Chromoblastomycosis is difficult to treat because of differences in antifungal sensitivity patterns and responses among the species isolated and also because of the refractory nature of the condition&#44; particularly in more serious clinical forms&#46;The different treatment modalities available have not been compared in clinical settings&#46; Recurrence is common&#44; hence the recommendation for long-term treatments&#44; lasting between 3 and 18 months&#44; depending on the study&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Possible complications include secondary bacterial infection with lymphadenitis and&#44; less frequently&#44; the development of squamous carcinoma in lesions that have been present for a very long time&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In our case&#44; the only complication was secondary impetiginization&#44; which was resolved with topical antibiotics&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Treatments can be divided into 3 broad modalities&#58; physical treatments&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> pharmacologic treatments&#44; and combined therapies&#46; Surgery may be the best choice in the early stages of disease&#44; but systemic antifungals are necessary in more advanced cases&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">A variety of treatment regimens have been attempted&#44; but it is impossible to determine the best option due to a lack of comparative clinical studies using objective criteria&#46; The best systemic antifungals seem to be itraconazole and terbinafine because of their spectrum of action and safety in long-term regimens&#46; However&#44; tissue fibrosis secondary to infection can reduce drug tissue levels&#46; Terbinafine may have antifibrotic properties that would favor the healing of chromoblastomycosis lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Terbinafine combined with cryotherapy has emerged as a possible treatment option in recent years&#46; Of all the physical treatments described in the literature&#44; cryotherapy is associated with the best outcomes&#44; with a cure rate of 40&#46;9&#37; when used as monotherapy&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Moreover&#44; it appears to be particularly useful when combined with systemic antifungals to treat long-standing lesions that are not candidates for surgery&#46; 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ISSN: 15782190
Original language: English
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