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Supportive treatment for severe or chronic diarrhea includes fluid and electrolyte replacement and, in some cases, parenteral nutrition 1 Cryptosporidiosis Treatment of cryptosporidiosis is challenging No agent is clearly effective Modest benefits have been seen in some (but not other) studies with paromomycin, a non-absorbed aminoglycoside (25 35 mg/kg for 14 days has been used), and nitazoxanide (up to 4 years of age: 100 mg twice daily; age 4 11 years: 200 mg twice daily; adults: 500 mg 1 g orally twice daily; length of therapy: 3 days for nonimmunocompromised and 2 8 weeks for advanced AIDS patients) Nitazoxanide was approved in the United States in 2002 for children with cryptosporidiosis or giardiasis but has also been used in adults It can cause mild gastrointestinal toxicity Other agents that have been used with mixed success in AIDS patients with cryptosporidiosis include azithromycin, spiramycin, bovine hyperimmune colostrum, and octreotide Reversing immunodeficiency with effective antiretroviral therapy is of greatest importance 2 Isosporiasis Isosporiasis is effectively treated in immunocompetent and immunosuppressed persons with trimethoprim-sulfamethoxazole (160 mg/800 mg 2 4 times daily for 10 days, with higher doses for patients with AIDS) An alternative therapy is pyrimethamine (75 mg in four divided doses) with folinic acid (10 25 mg/d) Maintenance therapy with low-dose trimethoprim-sulfamethoxazole (daily or three times per week) or Fansidar (weekly) prevents relapse in those with persistent immunosuppression 3 Cyclosporiasis Cyclosporiasis is also treated with trimethoprim-sulfamethoxazole (dosing as for isosporiasis) With AIDS, long-term maintenance therapy (three times weekly) helps prevent relapse For patients intolerant of trimethoprim-sulfamethoxazole, ciprofloxacin (500 mg orally twice daily for 7 days) showed efficacy, albeit with less ability to clear the organism than trimethoprim-sulfamethoxazole 4 Sarcocystosis For sarcocystosis, no specific treatment is established, but sulfadiazine cleared intestinal cysts in one study 5 Microsporidiosis Treatment of microsporidiosis is complex Albendazole has activity against a number of species, but its efficacy is relatively poor against E bieneusi, the most common cause of diarrhea in AIDS patients Infections with most species, including those causing gastrointestinal and other manifestations, should be treated with albendazole (400 mg twice daily for 2 4 weeks) For infections with E bieneusi, albendazole was effective in about half of patients in some studies Fumagillin, which is used to treat honeybees and fish with microsporidian infections, has shown benefit in clinical trials at a dose of 20 mg three times per day for 14 days; treatment was accompanied by reversible thrombocytopenia As with cryptosporidiosis, the best means of controlling microsporidosis in AIDS patients is to restore immune function with effective antiretroviral therapy Ocular microsporidiosis can be treated with fumagillin solution (3 mg/mL); this probably should be given with concurrent systemic therapy with albendazole Adjunctive management may include corticosteroids to decrease inflammation and keratoplasty.

Acquired nail disorders may be classified as local or those associated with systemic or generalized skin diseases

1 Onycholysis (distal separation of the nail plate from the nail bed, usually of the fingers) is caused by excessive exposure to water, soaps, detergents, alkalies, and industrial cleaning agents Candidal infection of the nail folds and subungual area, nail hardeners, and drug-induced photosensitivity may cause onycholysis, as may hyperthyroidism and hypothyroidism and psoriasis 2 Distortion of the nail occurs as a result of chronic inflammation of the nail matrix underlying the eponychial fold Such changes may also be caused by warts, tumors, or cysts, impinging on the nail matrix 3 Discoloration and crumbly thickened nails are noted in dermatophyte infection and psoriasis 4 Allergic reactions (to resins in undercoats and polishes or to nail glues) are characterized by onycholysis or by grossly distorted, hypertrophic, and misshapen nails

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1 Beau s lines (transverse furrows) may follow any serious systemic illness 2 Atrophy of the nails may be related to trauma or to vascular or neurologic disease 3 Clubbed fingers may be due to the prolonged hypoxemia associated with cardiopulmonary disorders (See 9) 4 Spoon nails may be seen in anemic patients 5 Stippling or pitting of the nails is seen in psoriasis, alopecia areata, and hand eczema

Onychomycosis may cause nail changes identical to those seen in psoriasis Careful examination for more characteristic lesions elsewhere on the body is essential to the diagnosis of the nail disorders Cancer should be suspected (eg, Bowen s disease or squamous cell carcinoma) as the cause of any persistent solitary subungual or periungual lesion

Toenail changes may lead to an ingrown nail in turn often complicated by bacterial infection and occasionally by exuberant granulation tissue Poor manicuring and poorly fitting shoes may contribute to this complication Cellulitis may result

FIGURE 10-2

Treatment consists usually of careful debridement and manicuring and, above all, reduction of exposure to irritants (soaps, detergents, alkali, bleaches, solvents, etc) Longitudinal grooving due to temporary lesions of the matrix, such as warts, synovial cysts, and other impingements, may be cured by removal of the offending lesion

treatment, the diagnosis should be confirmed The costs of the various treatment options should be known and the most cost-effective treatment chosen Drug interactions must be avoided Ketoconazole, due to its higher risk for hepatotoxicity, is not recommended to treat any form of onychomycosis For fingernails, ultramicronized griseofulvin 250 mg orally three times daily for 6 months can be effective Alternative treatments are (in order of preference) oral terbinafine 250 mg/d for 6 weeks, oral itraconazole 400 mg/d for 7 days each month for 2 months, and oral itraconazole 200 mg/d for 2 months Once clear, fingernails usually remain free of disease Onychomycosis of the toenails does not respond to griseofulvin therapy or topical treatments The best treatment, which is also FDA approved, is oral terbinafine 250 mg daily for 12 weeks Liver function tests and a complete blood count with platelets are performed monthly during treatment Pulse oral itraconazole 200 mg twice daily for 1 week per month for 3 months is inferior to standard terbinafine treatments, but it is an acceptable alternative for those unable to take terbinafine

Hay R Literature Onychomycosis J Eur Acad Dermatol Venereol 2005 Sep;19 (Suppl) 1:1 7 [PMID: 16120198] Heikkila H et al Long-term results in patients with onychomycosis treated with terbinafine or itraconazole Br J Dermatol 2002 Feb;146(2):250 3 [PMID: 11903235] Wilcock M et al Inappropriate use of oral terbinafine in family practice Pharm World Sci 2003 Feb;25(1):25 6 [PMID: 12661473]

2 Tinea Unguium (Onychomycosis)

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