The Japanese Dermatological Association produced some guidelines for the management of cutaneous fungal infection in cooperation with the Japanese Society for Medical Mycology, in which the importance of an accurate diagnosis of the fungal infection before antifungal treatment is emphasized. Here I comment on conventional mycological tests including direct microscopic examination and fungal cultures, which have been listed in the guidelines. Sampling of the clinical specimen is the most important step in mycological tests, so dermatologists should be aware of how and where good specimens are obtained. Direct microscopic examination of a KOH (potassium hydroxide) mounted preparation is the most simple and important test for diagnosing superficial fungal infection and dematiaceous fungal infection, which requires that dermatologists be skilled. The fungal culture is important in determining the therapeutic strategy and prophylaxis of the fungal infection, especially in cases of tinea capitis, tinea corporis, and deep mycoses. It is imperative that dermatologists be fully trained and prepared in order to implement these procedures when the occasion demands.

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In preparing guidelines for dermatomycosis (tinea, trichophytia, dermatophytosis), we have primarily summarized the disease types and treatments as described in 4 textbooks used in Japan and abroad. We present our classification draft based on these following descriptions. In Japan, any dermatophytosis other than favus or tinea imbricata is considered to be tinea, while outside Japan, favus and tinea imbricata are also classified as tinea. Tinea capitis is classified together with trichophytia superficialis capillitii and kerion celsi, in a group that tends to include asymptomatic carriers. Most textbooks generally classify trichophytia profunda of the glabrous skin and granuloma trichophyticum as subtypes of tinea corporis. Tinea faciei can easily be misdiagnosed, but in many cases can be distinguished from tinea corporis by its specific clinical picture. Tinea unguium is regarded as one type of onychomycosis.
We present a summary of dermatomycosis treatment as a proposal for future revision of the guidelines. One of the problems in the treatment of tinea capitis is that the safety of itraconazole (ITZ) and terbinafine hydrochloride (TBF) in children has not been established. Severity criteria for concomitant use of oral medications in the treatment of tinea pedis remains to should be established. Although many clinical studies concerning tinea unguium have been published, 3 of the 4 textbooks we consulted clearly stated that most of those studies were conducted by pharmaceutical companies. Further studies on the etiology and disease severity of tinea unguium are needed.

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This document summarizes current knowledge about diagnosis and treatment of candidiasis affecting the skin and oral mucosa. Several clinical forms of mucocutaneous candidiasis are distinguished depending on a patient's age and infected site, e.g. Candida intertrigo, erythema mycoticum infantile, erosio interdigitalis blastomycetica, candidal paronychia and onychia, Candida onychomycosis, and oral candidiasis. The diagnosis of candidiasis is confirmed by observation of mycelial forms on microscopic examination. Since Candida yeasts (especially C. albicans) are normal inhabitants of the skin and oral mucosa, it must always be noted that positive culture does not always indicate the presence of candidal infection. The pathogenicity of Candida species is relatively low, and some special conditions are required for tissue invasion by the fungus. Predisposing factors, such as disturbances of the cutaneous and mucosal microenvironment and systemic or local immunosuppression, should be checked in patients with recurrent infection. Therapy for cutaneous candidiasis is dominated by topical antifungal agents. Azole antifungal cream (e.g., bifonazole, ketoconazole, neticonazole hydrochloride, lanoconazole and luliconazole) is most effective. Terbinafine hydrochloride and amorolfine hydrochloride are also useful. Cutaneous candidiasis usually requires a shorter duration of topical treatment (1-2 weeks) than superficial dermatophyte infections. For candidal paronychia and onychomycosis, oral therapy with itraconazole is recommended. The daily dose of itraconazole should be taken for several months, while its pulse therapy for candidiasis is not approved in Japan. Itraconazole oral solution is commonly used for oral candidiasis, and miconazole gel is also effective.

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Sporotrichosis is a chronic infectious granuloma of skin. The detection of fungal elements in pathological examination and the isolation of Sporothrix schenckii from the lesion are requisite for diagnosis. The sporotrichin test is useful as an auxiliary examination, but a false-negative reaction might occur in some cases. Oral potassium iodide is first choice of treatment, because of its modest cost and usefulness, although gastrointestinal disorder is a frequent side effect. Itraconazole should be the second selection, and then terbinafine. Local thermotherapy is also effective as an additional therapy. Dematiaceous fungal skin infections are divided into two groups by their parasitic form, chromoblastomycosis and phaeohyphomycosis. Chromoblastomycosis is also called chromomycosis in Japan. It is most important for clinical diagnosis to detect dark brown spores in the scale of chromoblastomycosis and dark brown hyphae in the pus of phaeohyphomycosis by microscopic examination. Both morphological and molecular biological approaches are recommended for identification of fungi. In treatment, the drug appropriate in each case should be selected, and the combination of surgical excision, local thermotherapy, laser therapy or cryotherapy must be considered.

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In recent years, there have been reports on increases in non-albicans, and in this study, based on non-albicans isolated in the fields of surgery and emergency care as well as departments of hematology conducting the preventive administration of antifungal agents, we investigated the detected bacterial strains, detection rates, and trends in the results for susceptibility to antifungal agents, while focusing on rare Candida spp. According to the results, in the departments of hematology, rare Candida spp. were detected at high rates and the susceptibility was low. IN comparison to the fields of surgery and emergency care, the departments of hematology featured shifts toward rare Candida spp. rather than shifts toward C. glabrata or C. krusei. In the future, it will be necessary to pay attention to trends in the frequency of isolation and the results in regard to the susceptibility of rare Candida spp.

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A proportional increase in candidemia due to non-albicans Candida species has been reported worldwide. In our hospital, 36 of 58 candidemia cases were caused by non-albicans Candida species between 1996 and 2007. Candidemia due to non-albicans Candida species is associated with fluconazole(FLCZ)exposure. In our cases, 36 of 36 non-albicans candidemia cases received FLCZ while 18 of 22 albicans candidemia cases received this drug. In general, non-albicans Candida species including C. tropicalis, C. parapsilosis, and C. guilliermondii are susceptible to FLCZ. On the other hand, C. glabrata and C. krusei exhibit decreased susceptibility to FLCZ. Our in vitro susceptibility test revealed the same results as above although C. guilliermondii showed an elevated MIC to FLCZ(4-8 μ g/ml). In addition, both C. parapsilosis and C. guilliermondii showed elevated MICs to micafungin(1 μ g/ml and 0.5-2 μ g/ml, respectively)which is generally useful for non-albicans Candida species.

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Mucor is a mold which exists in nature, but mucor infections of humans, even in immunocompromised hosts, are rare. Clinical manifestations of mucormycosis are nonspecific and diagnosis is based on microscopic examination and culture of biopsy specimens. Serologic test or molecular methods of speciation are used only as research tools.
We investigated medical records especially for underlying diseases, clinical findings, treatment, and prognosis of patients diagnosed with rhinocerebral mucormycosis retrospectively in the Asan Medical Center.
The underlying diseases were diabetes mellitus in 8 patients, acute leukemia in 2, kidney transplantation in 2, and myelodysplastic syndrome in 1 of the total 13 patients. Six patients complained of nasal symptoms including stuffy nose, rhinorrhea, 5 patients complained of ophthalmic symptoms such as decreased visual acuity, diplopia, and ophthalmic pain and 2 of hard palate ulcer. The mortality was 23%(3/13; the two patients with kidney transplant, and one patient with acute leukemia).
In summary, mucormycosis should be considered in an uncontrolled DM and an immunocompromised host. The combined modality of early surgical debridement and antifungal agents was used for better treatment of rhinocerebral mucormycosis.

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We performed a comparative study of the effects of centrifugation, large amounts of inoculum and incubation temperature with regard to recovery of Candida albicans, Cryptococcus neoformans and Aspergillus fumigatus from fungal suspensions in order to identify optimal processing methods for mycological examination of clinical specimens. The number of fungal colonies, except for Candida spp., isolated from respiratory specimens, and the duration of incubation needed to isolate pathogenic fungi from clinical specimens were also analyzed retrospectively.
There was a difference in the number of recovered colonies, with or without centrifugation, between inoculum sizes of 10 μ l and 50 μ l, but no differences were observed in the results obtained under two sets of centrifugation conditions: 2,000 × g for 15 minutes and 3,000 × g for 20 minutes. Candida albicans and Aspergillus fumigatus developed more rapidly at 35 °C than at 27 °C in the first 24 hours of incubation, while Cryptococcus neoformans formed a larger colony at 27 °C than at 35 °C.
One to three colonies of Aspergillus spp. and Cryptococcus spp. were isolated from respiratory specimens in 73% and 50% of cases, respectively. The required incubation period was six days for isolation of 65 Aspergillus spp. strains from respiratory specimens, while 14 days was needed for isolation of 46 dermatophyte strains.
Based on these results, we recommend a pretreatment of centrifugation and a large quantity of inoculum for respiratory specimen processing, as well as an incubation period of at least 7 days and 21 days for internal and dermatological specimens, respectively.

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The antifungal activity of 43 hydrosols, 7 herbal teas and 12 essential oils was determined using Candida albicans as a test organism. All of the hydrosols examined showed more potent inhibition against the filamentous form than the yeast form of C. albicans. In particular, the filamentous form was markedly inhibited by seven hydrosols, of which monarda, santolina and clove water also inhibited the growth of the yeast form. Most of the inhibitory activity of the hydrosols was correlated with that of their respective major components. Poor correlation was observed between the inhibition of filament formation and the growth inhibition of the yeast form among the hydrosols examined, among essential oils and among the major components of hydrosols and essential oils. Seven herbal teas showed moderate or weak activity against the filament formation of C. albicans, but no inhibition against the yeast form.

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We report two cases of candidal onychomycosis with severe nail deformities. Case 1: The patient was an 81-year-old man who complained of onycholysis and nail deformity of the right forefinger nail which had occurred over a period of a year. He had no obvious previous illness. Case 2: The patient was an 81-year-old woman who complained of nail deformity with periungual erythema which had occurred over a period of several months. She had been treated with oral corticosteroid for bronchial asthma and with Ca blocker for hypertension for a long period.
The initial KOH-prepared direct microscopy in each case failed to detect any spores or pseudohyphae. Therefore, an incisional biopsy was performed in both cases. Histopathological findings demonstrated numerous fungal elements with similar appearance of dermatophytes in the middle to lower level of the horny cell layer by PAS and Grocott staining in each case. Candida albicans was isolated and identified by cultivation on ATG agar. In case 1, oral itraconazole (100 mg/day) was administered for 14 weeks, which was effective clinically and mycologically. In case 2, however, a coadministered drug (Ca blocker), oral terbinafine (125 mg/day) was not effective mycologically. Therefore, after having changed the antihypertensive agent, oral itraconazole (100 mg/day) was administered for 16 weeks, which was effective clinically and mycologically.

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Small amounts of contaminants may lead to false-positive results in sensitive polymerase chain reaction (PCR) detection systems. To analyze contaminants and understand the usability of β-glucanases in fungal preparations, we estimated the ribosomal DNA (rDNA) contamination in Zymolyase-100T and Lyticase by quantitative PCR. The amount of rDNA contamination determined by real-time PCR was 9210 copies/unit for Zymolyase-100T and 0.0323 copies/unit for Lyticase. The observations regarding these enzyme products indicate that careful consideration of contaminating DNA included in the reagents used for molecular diagnostics is necessary.

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