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Lyme Disease

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 itís 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 donít 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 Ö again, itís 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, itís fungus. But then again, half the time it isnít too. So itís important not to treat everybody with nails for fungus infection. Itís 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 thereís going to be one out soon, so Iíll 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. Itís 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 wonít go through this thing in detail, but itís 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 itís three to 18 weeks for terbinafine. The Sporanox lasts about 6-9 months, maybe 3-5 months for the Lamisil and Iíve 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 thatís 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. Hereís 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 thatís it. I still have patients coming back to me and saying, "Well, youíve 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 Ö 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 donít like to feed on you but if thereís no dog or cat. The cat flea is the most common in the