We report two cases with primary cutaneous aspergillosis. Case 1 was an 87-year-old woman. She visited us due to pain and erythema in a scar of the herpes zoster that occurred four years ago. There was an irregularly-shaped erythema and a minor erosion at the site of the herpes zoster scar (atrophic skin and hypopigmented spots) on the left side of her back. Although the patient was initially treated externally with an antiulcer drug for erosion, the erythema enlarged, with erosion and small pustules. A conventional culture of the pustule contents revealed Aspergillus niger. Therefore, we suspected primary cutaneous aspergillosis. A biopsy showed inflammatory cell infiltration in the upper dermis. Grocott staining showed mycelia only in the horny layer. All symptoms were cured by treatment with oral administration of itraconazole, washing of the wound, and external application of an antiulcer drug. 　Case 2 was a 53-year-old woman. While she was being treated for Cushing syndrome and psoriasis vulgaris, acute myeloid leukemia occurred and she was emergently transported to our hospital. When transferred to the hematology department, skin rashes were detected on her abdomen. There was a feverish infant’s head-sized erythema in the lower abdomen in which thick, hard, irregularly-shaped yellow-brown crusted ulcers were present. Since a conventional culture detected Aspergillus, primary cutaneous aspergillosis was suspected and a biopsy was performed. In the tissue specimen, inflammatory cell infiltration was observed in the entire dermal region, and Grocott staining showed a plethora of mycelia in the dermis. A fungal culture of the tissue detected Aspergillus fumigatus. Although the patient in case 1 was not immunocompromised, she had been afraid of touching the affected part of the herpes zoster that occurred four year ago when the herpes zoster was not cured. Since she had taken a bath with the affected part covered, in addition to a continuous external treatment with nadifloxacin ointment, the condition where the affected part had not been sufficiently washed was considered to be the causative factor. The patient in case 2 was an extremely obese woman and her skin overlapped in some regions in a standing position. When acute myeloid leukemia occurred, she spent several months in bed due to poor physical health and a bed bath could not be given, which was considered to be a causative factor. We consider that in immunocompromised patients, such as those with leukemia and elderly individuals, keeping the skin in unclean environments is a factor for enhancing Aspergillus infection and growth, leading to primary cutaneous aspergillosis.

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　For the treatment of onychomycosis, only oral drugs and topical medications not specifically indicated for this disease were available until a specific topical drug was released. In September 2014, a topical drug for onychomycosis was first marketed in Japan (efinaconazole: Clenafin^Ⓡ), and clinical results concerning its use for one year or longer have not yet been reported. We investigated 484 patients who were prescribed efinaconazole for treatment of onychomycosis at our department. Among the patients in whom cure was achieved, treatment for one year or longer was required in more than 30%, and the overall cure rate was 14.9% in the actual clinical setting. Among all patients, 81.3% showed improvement to some extent (including cure). With regard to safety, there were no systemic adverse reactions, while contact dermatitis was observed in 13 out of 484 patients. The launch of efinaconazole, which causes fewer adverse reactions, has provided an option for patients who would not show an adequate response to conventional treatments. In particular, this drug can be a first-line treatment for elderly patients and those using multiple oral medications. However, good patient adherence is crucial for a successful outcome, as well as assiduous management by the physician at the time of treatment initiation. A detailed explanation about the realistic prospect of cure should also be provided.

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