Case and Research Letters
Dermatitis of the Face and Neck: Response to Itraconazole
Dermatitis de cara y cuello. Respuesta a itraconazol
R. Ruiz-Villaverde, D. Sánchez-Cano
, D. López-Delgado
Corresponding author
Unidad de Dermatología Médico-Quirúrgica y Venereología, Complejo Hospitalario de Granada, Granada, España
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Ruiz-Villaverde, D. Sánchez-Cano, D. López-Delgado" "autores" => array:3 [ 0 => array:2 [ "nombre" => "R." "apellidos" => "Ruiz-Villaverde" ] 1 => array:4 [ "nombre" => "D." "apellidos" => "Sánchez-Cano" "email" => array:1 [ 0 => "ismenios@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "D." "apellidos" => "López-Delgado" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Dermatología Médico-Quirúrgica y Venereología, Complejo Hospitalario de Granada, Granada, España" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Dermatitis de cara y cuello. Respuesta a itraconazol" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1500 "Ancho" => 900 "Tamanyo" => 175098 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Response to therapy after 5 months of treatment.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We report the case of a 36-year-old woman with a personal history of seasonal rhinitis and atopic dermatitis (AD) dating from childhood. She consulted for worsening of AD accompanied by severe lesions caused by scratching on the trunk and limbs. The initial physical examination revealed a SCORAD severity score of 47 and major involvement of the skinfolds and trunk. The results of a laboratory workup were normal, with an immunoglobulin (Ig) E level<span class="elsevierStyleHsp" style=""></span>of<span class="elsevierStyleHsp" style=""></span>240<span class="elsevierStyleHsp" style=""></span>IU (N<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>IU). Before consulting, the patient had received various topical corticosteroids, emollients, and systemic corticosteroids (0.5-1<span class="elsevierStyleHsp" style=""></span>mg/kg/d), with which she achieved a partial response. She received treatment at another center with ciclosporin 3<span class="elsevierStyleHsp" style=""></span>mg/kg/d, which had to be suspended because of hypertension that was difficult to control despite the addition of amlodipine 20<span class="elsevierStyleHsp" style=""></span>mg/d. Successive treatment with azathioprine 50<span class="elsevierStyleHsp" style=""></span>mg/d, methotrexate 15<span class="elsevierStyleHsp" style=""></span>mg/wk, and mycophenolate mofetil 1.5<span class="elsevierStyleHsp" style=""></span>g/d had to be suspended because of gastrointestinal intolerance to the first 2 drugs and lack of response to the third. Treatment with narrowband UV-B was not considered, because the patient was unable to attend the sessions. During the switch to mycophenolate mofetil, the clinical expression of AD varied, with intense edema and erythema on the face and neck (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Therefore, the initial diagnosis proposed was head and neck dermatitis. We carried out a prick test with inhaled allergens from the standard series. The results were positive for <span class="elsevierStyleItalic">Alternaria</span> species, <span class="elsevierStyleItalic">Cladosporium</span> species, and cat dander and negative for gastrointestinal allergens, latex, and <span class="elsevierStyleItalic">Anisakis</span> species. The evaluation was completed with prick testing to <span class="elsevierStyleItalic">Malassezia</span> species and <span class="elsevierStyleItalic">Candida</span> species. The results were positive for the former and negative for the latter (tested with 20 healthy controls in the last 2 cases). Histopathology was consistent with AD. Treatment was started with itraconazole 100<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h for 1 month, which was tapered until 5 months of treatment had been completed. The patient's lesions improved considerably (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The prevalence of adult AD ranges from 0.3% to 14%, with the most widely accepted range being that of 1%-3%.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> In adults, pruriginous eczema affecting the face, neck, and upper thorax is known as head and neck dermatitis. It is associated with intense pruritus and a major alteration of the patient's quality of life. Curiously, the activity of AD at other sites is usually minimal or moderate. In terms of etiology and pathology, it has been associated with hypersensitivity (but not overgrowth) caused by different subspecies of the lipophilic mold <span class="elsevierStyleItalic">Malassezia</span> (<span class="elsevierStyleItalic">Malassezia furfur, Malassezia restricta, Malassezia sympodialis</span>, and <span class="elsevierStyleItalic">Malassezia globosa</span>). Increased colonization by <span class="elsevierStyleItalic">Malassezia</span> species of specific areas of the body has been observed in pubertal patients and young adults. In this case, the areas affected were the same as those affected in head and neck dermatitis, compared with healthy skin and compared with healthy persons.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The host immune response to <span class="elsevierStyleItalic">Malassezia</span> species was assessed using prick testing, determination of specific IgE, and patch testing.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Most studies have not simultaneously compared the response to <span class="elsevierStyleItalic">Candida</span> species, staphylococci, streptococci, and <span class="elsevierStyleItalic">Trichophyton</span> species. In the immune response, it seems that stimulation of B lymphocytes plays a more important role than delayed T lymphocyte–mediated hypersensitivity. Similarly, some studies correlate the severity of head and neck dermatitis with specific IgE levels to <span class="elsevierStyleItalic">Malassezia</span> species.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a> This hypersensitivity is greater in patients with allergic rhinoconjunctivitis or asthma,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> as observed in the present case.</p><p id="par0020" class="elsevierStylePara elsevierViewall">With respect to therapy, there is no well-defined protocol to enable a suitable approach to this condition. Outcome with topical antifungal agents does not seem to be satisfactory. Systemic therapy has focused on the use of ketoconazole 200<span class="elsevierStyleHsp" style=""></span>mg/d or itraconazole 100-400<span class="elsevierStyleHsp" style=""></span>mg/d, and it is necessary to wait a month before results appear in most patients.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Series that present a more extensive cohort of patients<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a> apply different itraconazole schedules over periods ranging from 7 days to 2 months. It seems reasonable to initiate treatment at 100-200<span class="elsevierStyleHsp" style=""></span>mg/d and to evaluate the effect of therapy at 1 month in order to reduce to a minimum therapeutic dose that could be used over a longer period.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> The main reported adverse effects were flushing and headache, which resolved after interruption of treatment and enabled treatment to be reintroduced. Routine laboratory testing is not necessary in the absence of baseline liver disease or of associated contraindications. Case reports have shown that the condition can be controlled and therapy can subsequently be combined with other immunosuppressants, such as azathioprine, thus leading to a successful outcome.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:2 [ "identificador" => "xack374510" "titulo" => "Acknowledgments" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ruiz-Villaverde R, Sánchez-Cano D, López-Delgado D. Dermatitis of the Face and Neck: Response to Itraconazole. Actas Dermosifiliogr. 2018;109:829–831.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1600 "Ancho" => 900 "Tamanyo" => 239612 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythema and edema on the face and neck at the initiation of treatment with itraconazole.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1500 "Ancho" => 900 "Tamanyo" => 175098 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Response to therapy after 5 months of treatment.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dermatitis atópica del adulto: un reto diagnóstico y terapéutico" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 22 | 9 | 31 |
| 2024 October | 183 | 39 | 222 |
| 2024 September | 193 | 28 | 221 |
| 2024 August | 176 | 74 | 250 |
| 2024 July | 141 | 40 | 181 |
| 2024 June | 164 | 45 | 209 |
| 2024 May | 153 | 38 | 191 |
| 2024 April | 145 | 59 | 204 |
| 2024 March | 144 | 30 | 174 |
| 2024 February | 145 | 38 | 183 |
| 2024 January | 116 | 32 | 148 |
| 2023 December | 138 | 29 | 167 |
| 2023 November | 146 | 27 | 173 |
| 2023 October | 130 | 29 | 159 |
| 2023 September | 113 | 35 | 148 |
| 2023 August | 108 | 24 | 132 |
| 2023 July | 132 | 45 | 177 |
| 2023 June | 103 | 35 | 138 |
| 2023 May | 124 | 37 | 161 |
| 2023 April | 101 | 29 | 130 |
| 2023 March | 111 | 32 | 143 |
| 2023 February | 142 | 33 | 175 |
| 2023 January | 80 | 45 | 125 |
| 2022 December | 90 | 55 | 145 |
| 2022 November | 80 | 39 | 119 |
| 2022 October | 59 | 21 | 80 |
| 2022 September | 71 | 39 | 110 |
| 2022 August | 58 | 36 | 94 |
| 2022 July | 35 | 61 | 96 |
| 2022 June | 34 | 40 | 74 |
| 2022 May | 107 | 50 | 157 |
| 2022 April | 118 | 38 | 156 |
| 2022 March | 89 | 44 | 133 |
| 2022 February | 119 | 28 | 147 |
| 2022 January | 138 | 52 | 190 |
| 2021 December | 90 | 52 | 142 |
| 2021 November | 88 | 54 | 142 |
| 2021 October | 103 | 51 | 154 |
| 2021 September | 115 | 52 | 167 |
| 2021 August | 145 | 31 | 176 |
| 2021 July | 122 | 33 | 155 |
| 2021 June | 115 | 47 | 162 |
| 2021 May | 108 | 52 | 160 |
| 2021 April | 180 | 85 | 265 |
| 2021 March | 150 | 42 | 192 |
| 2021 February | 148 | 45 | 193 |
| 2021 January | 94 | 38 | 132 |
| 2020 December | 93 | 44 | 137 |
| 2020 November | 70 | 32 | 102 |
| 2020 October | 67 | 19 | 86 |
| 2020 September | 116 | 30 | 146 |
| 2020 August | 32 | 30 | 62 |
| 2020 July | 19 | 20 | 39 |
| 2020 June | 32 | 34 | 66 |
| 2020 May | 25 | 23 | 48 |
| 2020 April | 17 | 12 | 29 |
| 2020 March | 19 | 9 | 28 |
| 2020 February | 3 | 2 | 5 |
| 2019 May | 2 | 0 | 2 |
| 2018 November | 1 | 0 | 1 |
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