FUNGUS INFECTIONS

The introduction of griseofulvin has provided an effective means of treating ringworm of the scalp, including favus, and is an improvement in the treatment of ringworm of the nails. Nevertheless, it is not very effective in ringworm of the feet (athlete's foot) nor is it effective against yeasts; thus monilial paronychia and systemic monilial infections are not helped by it. Griseofulvin is taken by mouth and it becomes loosely incorporated in skin, hair and nails during their growth, making them unacceptable to the fungi which thus find themselves deprived of their usual food—freshly formed keratin—and they are cast off as the keratin containing tissues undergo normal wastage by; desquamation, etc. The recommended dose is i g. daily in divided doses but, a if the finely divided form of griseofulvin is used, half this amount is stated to be effective. Reduction of the dose below the recommended level is likely to prove ] unsatisfactory. In treating ringworm of the scalp a course lasting six weeks is usually required, and it should be combined with the local use of Whitfield's ointment and clipping the hair short. The proper duration of treatment is very difficult to assess even with full mycological control, and it is possible that further experience will modify current views on this dosage. In ringworm of the nails; the treatment will have to be continued for nine months or more until the last ^ traces of the diseased nail have disappeared. The local use of fungicides is recommended, for example magenta paint B.P.C., and removal of the diseased, I friable nail is desirable. This can be done by using a piece of broken glass or; sandpaper as a scraper; all the scrapings should be burnt. Very few toxic effects have resulted from treatment with griseofulvin apart from mild gastro-intestinal upset; disturbance of porphyrin metabolism has also been reported.

Tinea Pedis.—This extremely chronic infection usually takes the form of macerated skin between the toes which causes little trouble until the feet get I very hot when there is liable to be an explosive outbreak of an acute eczema with i vesiculation due to the fungus growing vigorously in the skin under the warm, i moist conditions. Should this exacerbation provoke an ide eruption, it is important to realize that the ide does not contain active fungus elements and it is, therefore, appropriate to treat it as an eczema without using fungicides. The active fungus infection should be treated as an acute eczema initially, using soaks or wet dressings and confining the patient to bed if there is lymphangitis. It is usual to give an anti-infective agent orally for its systemic effect; this should preferably be a sulphonamide because an antibiotic might produce an unpleasant reaction if, as an antigen, it has something in common with the fungus present in the patient's eczematous skin. Fungicides such as Whitfield's oint­ment (benzoic acid compound ointment, B.P.C.) and Castellani's paint (magenta paint, B.P.C.) are used when the eruption is less angry in appearance. In the resting phase the disease is sometimes intractable. If an attempt is made to eradicate the disease, it is essential to keep the skin as clean, dry and cool as possible, to destroy fungus present on the footwear, to prevent re-infection and to continue using fungicides. In order to comply with this advice, the patient needs to adhere to a very exacting programme of personal hygiene. He should wash his feet twice daily in soap and water and dry the skin very carefully afterwards, using a towel kept exclusively for his use. Dead skin should be removed with forceps, not the finger nails ; and Whitfield's ointment should be rubbed thoroughly into the webs between the toes, after which the feet and the socks should be dusted with zinc undecenoate dusting power, B.P.C. He should wear a thin pair of white cotton socks next to the skin, putting on a clean pair after every washing and having the dirty pair boiled. His oversocks should be thin and—in order to minimize sweating—not made of synthetic fibre. He should wear thin, leather-soled shoes or sandals. The inside of his shoes should be treated with formalin vapour, but great care should be taken to leave as little as possible in the shoe or he will develop a contact eczema. If he perseveres with these instructions for some months he may be cured but, if he is, he will have to continue taking precautions against re-infection for the rest of his life by refusing to walk anywhere in bare feet (except on his own bath mat) and by continuing to take particular care of his feet, using zinc undecenoate ointment, B.P. prophylactically.

Cattle Ringworm.—In farming areas ringworm derived from farm animals causes severely inflamed lesions (kerion). They are self limited because the severity of the reaction casts the fungus off the skin. The pustulation that occurs is not due to secondary infection so much as to hypersensitivity developed against the causative fungus, so that oral corticosteroid therapy has a place in very severe infections. To allow the disease to take its course may involve an illness of 8 to 16 weeks but its duration can be reduced by giving griseofulvin by mouth for two or three weeks early in the course of the infection. After having removed the debris by gentle washing or with starch poultices and having clipped the surrounding hair short, local dressings are applied : they consist of 5 per cent. ichthammol in water used as wet dressings under oiled silk. Later an ointment, containing equal parts of a corticosteroid ointment and Whitfield's ointment, should be rubbed in thoroughly twice daily until all pustulation has ceased. The remaining lumpiness can then be left to settle spontaneously. It should be noted that although large lesions are tumid and studded with pustules, no benefit is obtained by incision because the pus is contained within the individual hair follicles and is not amenable to the knife.

Tinea Circinata.—Ringed lesions of the open skin usually respond quickly to. Castellani's paint or to Whitfield's ointment. Infections due to Trichophyton rubrum may prove resistant (onvchia is almost certain to co-exist) and then griseofulvin by mouth would be indicated. The diagnosis of tinea circinata calls for consideration of the origin of the infection ; the scalp should be examined for the scalv, bald patches of ringworm, and inquiry should be made about possible animal sources—particularly proximity to kittens and puppies.

Scalp Ringworm.—Griseofulvin is the treatment of choice. Epilation by X-rays or by thallium acetate is now unnecessary. It is very desirable that the public health and school medical authorities should be informed of cases that occur so that they can take steps to trace the source of infection and to find all the cases in order to prevent epidemic spread of the disease.

Groin Infections.—The infection often stems from the feet which should be treated simultaneously. If the skin is acutely inflamed treatment should first be that used in acute eczema; and when the angry phase has subsided fungicides may be applied, for example Whitfield's ointment or Castellani's paint. When the infection appears to have been cured the patient should still take the precaution of drying himself thoroughly after his bath, and should dust the skin with zinc undecenoate powder B.P.C.

Nail Infections.—Formerly, infection of the nails with fungus was often incurable even though the affected nails were avulsed and fungicides applied during their subsequent growth. With griseofulvin the results are sometimes good and permanent cure can occur.


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