| Comments from Faculty and Members |
Steven Chow FRCPI, Senior Consultant Dermatologist,
Pantai Medical Centre, Kuala Lumpur, Malaysia on May
14, 2007
I have a similar patient who has been on long term itraconazole
100mg daily for the past 5 years. She has excellent tolerance
of the treatment. The disease is under control and relapses
when she defaults therapy. Topical treatment is of little value.
Rick Sontheimer MD, Professor of Dermatology, Department
of Dermatology, University of Oklahoma Health Science Centre,
Oklahoma City, OK, USA on May 14, 2007
I agree that the photographs and history are consistent with
chronic mucocutaneous candidiasis. I have no recent experience
in treating this disease. However, I think it would be important
to subphenotype this patient if at all possible via referral
to a pediatric immunodeficiency clinic. Some forms of this disease
are associated with other medical problems (e.g. poly endocrinopathies).
In addition, this patient and her family deserve appropriate
genetic counseling.
Khalifa Sharquie MD, Professor of Dermatology, College
of Medicine, University of Baghdad, Baghdad, Iraq on
May 15, 2007
Although both conditions psoriasis and candidiasis can share
some features but the picture is more in favour of psoriasis
especially the scalp and the nail changes. So please do therapeutic
antifungal trial and biopsy to confirm the diagnosis.The Presense
of candida could be a secodary invader rather than as a primary
cause.
Ijaz Hussain MD, Professor of Dermatology, Sheikh Zyad
Medical College, RYK, Pakistan on May 17, 2007
I must congratulate Dr. Ian for such beautiful pictures. Regarding
this case:
1. CMC itself is a group of multiple disorders. Primary defect
as far I know is selective immunodeficiency against Candida
spp. It may be associated with many other endocrinopathies,
infections etc. Family history is important.
2. Since the nails are affected oral fluconazole and short duration
of therapy would be insufficient as (a) Fluconazole is a less
keratophilic drug, its binding with nail keratins, MIC in the
nail matrix required for C. albinans would not be achieved.
and (b) As in onychomycosis we require a longer duration of
treatment e.g. 6 weeks at least, the duration of treatment would
be longer in this particular case too.
Choon Siew Eng FRCP Senior Consultant Dermatologist,
Hospital Sultanah Aminah, Johor Bahru, Malaysia on
May 17, 2007
Years ago, I treated a 6-year-old boy with very similar lesions.
I put him on ketoconazole for 6 months together with oral cimetidine.
I had a 3-year-old girl recently in HSAJB and treated her with
itraconazole. She responded well.
Laxmisha Chandrashekar MD, Lecturer in Dermatology,
Christian Medical College, Vellore, India on May 18,
2007
She definitely needs HIV test and endocrine evaluation. She
also needs iron studies. She may benefit from iron supplements,
levamisole 75mg BD twice weekly, along with ketoconazole.
Anne Junker MD, Professor of Paediatrics (Immunology),
University of British Columbia, Vancouver, BC, Canada
on June 1, 2007
Poor kid! We saw a few kids in earlier days, before CMC went
by the board as a "distinct" syndrome. Treatment is
obviously antifungals, long term; often relapsing disease or
development of antimicrobial resistance. We had one child who
"grew out of" this -- lots of problems as an infant
and toddler, which resolved by school age. There seems to be
a view that CMC is associated with a variety of immune defects,
rather than a distinct syndrome with unique abnormality in immune
function. The largest association is CMC with autoimmune polyendocrinopathy
type 1, due to mutations in the AIRE (autoimmune regulator)
gene. These patients may have normal T cell function, but problems
dealing with candida due to defective antigen presentation and
downstream responses. There is also association with thymoma,
but this is pretty rare in little kids.
Pramod Kumar MD, Consultant Dermatologist, Saham Hospital,
Oman on June 15, 2007
I have a similar case. A automechanic presented with typical
candidiasis and satellite lesions on hands,gradually increasing
to dorsum of hands,wrists,elbows, knees and legs.Scalp and mucosae
are still free.I treated him for Candidiasis with Fluconazole
weekly.The lesions did not spread in number or size.But the
hyperkeratosis would not go.I have reviewed my diagnosis to
Psoriasis and put him on methotrexate weekly 15 mg and his lesions
have already melted.All lab parameters were normal.In my view
like guttate variety, Candidiasis can precipitate Psoriasis
as is likely in this case.
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