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Lyme disease is erythema chronicum migrans. We get a ton of people coming in saying, "I got bit by a tick and I got something on my skin and I think it’s Lyme disease." But there is a specific appearance to that lesion. Then iliychiosis, which is becoming more and more widely reported, particularly in the Southeast, the so-called Rocky Mountain Spotless fever. You have all this sequelae, the low platelets, thrombocytopenia, the headache the fever, but you don’t have the skin disease to tip you off the Rocky Mountain Spotted Fever. This is erythema chronicum migrans with Lyme disease. What it is, is a spreading red ring and they do look like that. And all the various things that people come in with … again, it’s a spreading red ring that spreads out.
Onychomycosis, fungal infections of the nail for a few minutes here. About half the people who come in with nail disorders have a fungal infection, so if somebody has something wrong with the nail, it’s fungus. But then again, half the time it isn’t too. So it’s important not to treat everybody with nails for fungus infection. It’s on the rise due to the aging population and also in the immunocompromised patients. I thought this was interesting. This is the number of times patients with the diagnosis come into dermatologists as opposed to other specialties and if you look down her
How do you treat the patients? Well, I want to only talk about the two main ones now because fluconazole has only one study and there’s going to be one out soon, so I’ll talk about the two that are approved for treatment of nail infections. Terbinafine, which is Lamisil, which is a fungicidal drug, mainly against dermatophytes; ring-worm. And has been approved for treatment of nail infections with a dose of 250 mg once a day for three months. Itraconazole or Sporanox is considered fungistatic in vivo at least, but it has activity against not only Trichophyton, which is mainly what you are going to see for dermatophytes, but also for Candida and also the molds. It’s approved for treatment of onychomycosis at 200 mg twice a day for seven days, which is the so-called pulse treatment. Is does work very nicely. One pulse for skin, two pulses of fingernails and three pulses for toenails.
I won’t go through this thing in detail, but it’s a list of some of the characteristics of the antifungal medicines. Just for terbinafine and itraconazole, the time to reach the nail is only seven days and itraconazole it’s three to 18 weeks for terbinafine. The Sporanox lasts about 6-9 months, maybe 3-5 months for the Lamisil and I’ve already talked about what they are active against. So anyway, they come there very quick, particularly itraconazole and they stay there for a long time, and that’s why you can use the short doses.
This is just one study treating nails with Sporanox, itraconazole, with the pulse therapy and they had, I think, a 84% cure rate in that study. This is the way it looks schematically with itraconazole. Three pulses. Here’s the baseline toenail. You give the first pulse. At the end of three weeks they get the second pulse, and the end of the third week you give the third pulse and that’s it. I still have patients coming back to me and saying, "Well, you’ve done this.
Melanoma. In 1930 the lifetime risk of melanoma was 1 in 1,500. In 1980 the risk had dropped to 1 in 250. In 1980 the predicted incidence was 1 in 150 and by the year 2000 that mark was … it was supposed to be 1 in 150 by the year 2000. That mark was reached in 1985, 15 years earlier than expected. The 1997 estimate of melanoma is 1 in 84. The new estimate for the year 2000 is 1 in 75. So these are scary numbers. Just a story. There is a
Fleas. Of course everybody knows, small wingless, jumping insects. Vectors of disease worldwide. Plague, a lot of things in other countries. Dog tapeworm. Feeds on domestic animals and humans, but it would rather feed on a dog or a cat. They don’t like to feed on you but if there’s no dog or cat. The cat flea is the most common in the