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LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Year : 2017  |  Volume : 83  |  Issue : 1  |  Page : 69-70

Author's reply


Department of Dermatology, Venereology and Leprosy, MGM Medical College and Hospital, Navi Mumbai, Maharashtra, India

Date of Web Publication2-Dec-2016

Correspondence Address:
Shaurya Rohatgi
502/A, Sai Prasad Residency, Kharghar Sector 10, Navi Mumbai - 410 210, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0378-6323.195074

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How to cite this article:
Ardeshna KP, Rohatgi S, Jerajani HR. Author's reply. Indian J Dermatol Venereol Leprol 2017;83:69-70

How to cite this URL:
Ardeshna KP, Rohatgi S, Jerajani HR. Author's reply. Indian J Dermatol Venereol Leprol [serial online] 2017 [cited 2017 Jan 17];83:69-70. Available from: http://www.ijdvl.com/text.asp?2017/83/1/69/195074


Sir,

We thank the authors for showing interest in our paper and accepting our arguments justifying the use of isotretinoin in dermatophytosis. While there are concerns on the rationality of this combination, we want to highlight yet again that the use of this combination should only be reserved for recalcitrant cases.[1]

It is likely that the increased cell turnover brought about by isotretinoin may result in faster clearance of itraconazole from the skin, thereby also reducing the reservoir effect. However, the argument put forward by the authors is based on concentration of any drug in isolation is of limited value and should ideally be analyzed along with concomitant pharmacodynamic data.[2] For example, amphotericin B deoxycholate and itraconazole have low concentrations in the cerebrospinal fluid yet they are effective agents for the treatment of cryptococcal meningitis.[2] Tissue homogenates are frequently used to estimate tissue concentrations but they are a relatively crude and potentially misleading matrix when used for this purpose.[2] Mouton et al. have highlighted the potential pitfalls in using drug concentrations within whole-tissue homogenates for drawing conclusions related to the activity and efficacy of a drug, especially for extracellular pathogens.[3] Moreover, studies trying to correlate in vitro dermatophyte minimal inhibitory concentrations with clinical outcomes have often failed to produce definitive results.[4] Despite our counterargument, we agree that further in-depth studies are required to evaluate the effect of isotretinoin on pharmacokinetics and pharmacodynamics of itraconazole.

Since isotretinoin decreases sebum production and sebum being a major route of delivery of itraconazole to the stratum corneum, it can possibly reduce the bioavailability of the drug to infected sites. Our first argument holds valid for this query as well. We do not know much about the impact of isotretinoin on the pharmacokinetics of itraconazole although it is plausible theoretically.

The final query was regarding inadequate duration of therapy resulting in poor response and possible relapse. We agree that continuing the same oral antifungal for longer period might have given better result. However, according to literature [5],[6],[7],[8] and dermatology textbooks,[9],[10], the recommended dose and duration of treatment for tinea cruris/corporis with oral itraconazole is 100 mg/day for 2 weeks or 200 mg/day for 1 week. In fact, this duration is also advocated in the package insert of itraconazole (Sporanox ®).[11] We used the same regimen for our patient; nevertheless considering the present scenario of relapsing dermatophytosis in our country, longer treatment schedule may be required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ardeshna KP, Rohatgi S, Jerajani HR. Successful treatment of recurrent dermatophytosis with isotretinoin and itraconazole. Indian J Dermatol Venereol Leprol 2016;82:579-82.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Felton T, Troke PF, Hope WW. Tissue penetration of antifungal agents. Clin Microbiol Rev 2014;27:68-88.  Back to cited text no. 2
    
3.
Mouton JW, Theuretzbacher U, Craig WA, Tulkens PM, Derendorf H, Cars O. Tissue concentrations: Do we ever learn? J Antimicrob Chemother 2008;61:235-7.  Back to cited text no. 3
    
4.
Martinez-Rossi NM, Peres NT, Rossi A. Antifungal resistance mechanisms in dermatophytes. Mycopathologia 2008;166:369-83.  Back to cited text no. 4
    
5.
Grant SM, Clissold SP. Itraconazole. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic use in superficial and systemic mycoses. Drugs 1989;37:310-44.  Back to cited text no. 5
    
6.
De Doncker P, Cauwenbergh G. Management of fungal skin infections with 15 days itraconazole treatment: A worldwide review. Br J Clin Pract Suppl 1990;71:118-22.  Back to cited text no. 6
    
7.
Degreef H, Mariën K, De Veylder H, Duprez K, Borghys A, Verhoeve L. Itraconazole in the treatment of dermatophytoses: A comparison of two daily dosages. Rev Infect Dis 1987;9 Suppl 1:S104-8.  Back to cited text no. 7
    
8.
Korting HC, Schöllmann C. The significance of itraconazole for treatment of fungal infections of skin, nails and mucous membranes. J Dtsch Dermatol Ges 2009;7:11-9.  Back to cited text no. 8
    
9.
Elewski BE, Hughey LC, Sobera JO, Hay R. Fungal diseases. In: Bolognia JL, Jorizzo JL, Schaffer JV, editors. Dermatology. 3rd ed. Philadelphia: Elsevier Saunders; 2012. p. 1251-84.  Back to cited text no. 9
    
10.
Hay RJ, Ashbee HR. Fungal infections. In: Griffiths C, Barker J, Bleiker T, Chalmers R, Creamer D, editors. Rook's Textbook of Dermatology. 9th ed. Oxford: John Wiley & Sons, Ltd.; 2016. p. 32.1-96.  Back to cited text no. 10
    
11.
Sporanox ® (Itraconazole) Capsules [Package insert on the Internet]. Titusville, NJ, USA: Janssen Pharmaceuticals, Inc.; 2001. Available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020083s040s041s044lbl.pdf. [Last revised on 2014 Jun; Last accessed on 2016 Oct 11].  Back to cited text no. 11
    




 

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