Porokeratoma in the nipple: A case report.

Abstract

challenging. Organ transplantation accompanied with immunosuppressive treatments is an important risk factor for alternariosis T incidence rate. Post-transplantation patients often have difficulty withstanding systemic antifungal therapy; amphotericin B potentially causes renal toxicity, and itraconazole can interact pharmacologically with immunosuppressive treatments. Torres-Rodr ıguez et al. reported a case of subcutaneous alternariosis treated with persistent thermotherapy without antifungal treatment. Suda et al. reported a case of cutaneous alternariosis initially treated with itraconazole (200 mg/day p.o.), which was later switched to voriconazole (400 mg/day p.o.). Skin lesions regressed following combination therapy with thermotherapy; however, the patient suffered from rotary vertigo and liver damage due to antifungal therapy use. Here, we present a case of cutaneous alternariosis successfully treated using thermotherapy combined with terbinafine hydrochloride 1% cream in a renal transplant patient. Following kidney transplantation for diabetic nephropathy, a 54-year-old woman received tacrolimus (0.1 mg/kg/ day), mycophenolate mofetil (1 g/day) and methylprednisolone (60 mg/day). One year after transplantation, she observed a red papule on her right forearm without previous trauma and subjective symptoms, which grew to form a protruding, irregular, 5 9 7 cm large, reddish plaque over a period of 1 year (Fig. 1a). Serum b-d-glucan levels were within the normal range. Histopathological analysis showed the presence of numerous spherical bodies and infiltration of inflammatory cells, mainly lymphocytes and histiocytes, in the dermis (Fig. 1b and c). Grocott staining revealed several spores and hyphae in the dermis (Fig. 1d and e). Fungal cultures of the biopsy specimen produced colonies with the morphology of Alternaria species, that is brown-olivaceous colonies and conidia with transverse and longitudinal or oblique septa (Fig. 1f and g). Considering the side effects of systemic antifungal therapy in immunosuppressed individuals and the progressive enlargement and depth of alternariosis, we applied thermotherapy combined with terbinafine hydrochloride 1% cream. Disposable adhesive heat pads at 50–55°C were applied for 12 h/day every day, and terbinafine cream once a day. After 6 months of this combination therapy, the plaque had completely resolved (Fig. 1h). Histopathological analysis revealed no fungal structures and cultures of biopsy samples exhibited no fungal growth. No relapse was detected over an 8-month follow-up. Granted the mechanism of this combination therapy remains unclear, it could nevertheless accelerate the treatment period compared to thermotherapy alone; the combination therapy took 6 months and the thermotherapy alone took 1 year. Note that metastatic/disseminated infection should be excluded especially in heavily immunocompromised patients prior to use of local therapy. This combination therapy could be a safe and effective treatment option for cutaneous alternariosis, especially in post-transplantation patients. Tomoka Harada | Takeshi Fukumoto | Korefumi Nakamura | Kenichiro Ohnuma | Chikako Nishigori Division of Dermatology, Department of Internal Related, Kobe University Graduate School of Medicine, Kobe and Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan