今日の臨床サポート

体部白癬

著者: 常深祐一郎 埼玉医科大学 皮膚科

監修: 戸倉新樹 掛川市・袋井市病院企業団立 中東遠総合医療センター 参与/浜松医科大学 名誉教授

著者校正/監修レビュー済:2020/06/19
参考ガイドライン:
患者向け説明資料

概要・推奨   

  1. 体部白癬の診断に際しては鏡検を行うことを強く推奨する(推奨度1)。
  1. 体部白癬に対して抗真菌薬の外用は強く推奨される(推奨度1)。
  1. 大きな病変、患者が自分で手の届かない部位やみえない部位(背部など)、複雑な部位(会陰部など)の病変、目や鼻、口、被髪頭部にかかる顔の病変などは抗真菌薬の外用ができないか困難であるので、経口抗真菌薬を併用を推奨する。ただし、体部白癬全例には推奨できない(推奨度2)。
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となりま
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
常深祐一郎 : 講演料(エーザイ株式会社,科研製薬,佐藤製薬,鳥居薬品,マルホ)[2021年]
監修:戸倉新樹 : 講演料(田辺三菱,サノフィ,マルホ,協和キリン),研究費・助成金など(ノバルティス,レオファーマ)[2021年]

改訂のポイント:
  1. 皮膚真菌症診療ガイドラインの改訂にあわせて、整合性を持たせるため、表現の修正を行ったが、内容に変化はない。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 白癬菌の生毛部(体表の皮膚のうち、頭髪やひげなどの硬毛部と掌蹠を除いた部分で、いわゆるうぶ毛のある部分)の皮膚への感染症である。顔面白癬を別にすることもあるが、本項では顔面白癬も体部白癬に含める。
  1. 疫学データはないが、皮膚科を受診する患者の13.8%が真菌感染症であり、そのうち87.1%が白癬で、白癬のなかの7.4%が体部白癬であったという調査結果がある。つまり、皮膚科の外来患者の0.89%が体部白癬ということになる。
  1. 自分の足白癬や爪白癬からの感染、動物からの感染のほか、一部他人からの感染もある。
  1. 湿疹などと誤診してステロイド外用を行うと悪化するが、的確に診断し、適切な治療を行えば比較的容易に治癒させることができる
  1. 多くの場合、環状の皮疹を呈するため、環状の皮疹をみた場合には必ず体部白癬を考えて、鏡検を行う。
問診・診察のポイント  
  1. 環状に配列する紅斑や丘疹をみたら体部白癬を考える。 鱗屑をつけていることが多いが、鱗屑が少ないこともある。
  1. ステロイドを外用しても改善しないという病歴を聞いたら体部白癬を考える。

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文献 

著者: L A Drake, S M Dinehart, E R Farmer, R W Goltz, G F Graham, M K Hardinsky, C W Lewis, D M Pariser, J W Skouge, S B Webster, D C Whitaker, B Butler, B J Lowery, B E Elewski, M L Elgart, P H Jacobs, J L Lesher, R K Scher
雑誌名: J Am Acad Dermatol. 1996 Feb;34(2 Pt 1):282-6.
Abstract/Text
PMID 8642094  J Am Acad Dermatol. 1996 Feb;34(2 Pt 1):282-6.
著者: Almuth Dinkela, Julia Ferié, Marco Mbata, Marco Schmid-Grendelmeier, Christoph Hatz
雑誌名: Int J Dermatol. 2007 Oct;46 Suppl 2:23-8. doi: 10.1111/j.1365-4632.2007.03208.x.
Abstract/Text BACKGROUND: Superficial dermatomycoses are a common problem in tropical regions. Due to limited resources, specific antimycotic therapy is often not available. The present study was performed to assess the clinical efficacy of the antimicrobial agent Triclosan in bar soap in comparison with regular soap against selected superficial dermatomycoses in Tanzanian schoolchildren.
METHODS: 820 primary school children were examined for skin disorders and 224 of these were included in the soap trial. The clinical presentation of dermatomycoses was recorded using a symptom score. Samples were taken for microscopic examination and mycological culture. The study participants received either bar soap containing Triclosan or a placebo for 2 months. They were re-examined at the end of this period.
RESULTS: The benefit achieved by the addition of Triclosan was not statistically significant. Overall cure rates for Triclosan and placebo groups taken together were 21.8% for tinea versicolor, 58.3% for tinea capitis, 55.5% for tinea corporis and 68.8% for tinea pedis. This was confirmed microscopically. For the majority of the children the dermatomycoses improved significantly.
CONCLUSIONS: The results strongly argue for regular soap use against common dermatomycoses as a low-cost and effective treatment. This promising finding should be considered in settings where dermatophyte infections represent a public health problem and where access to appropriate treatment and financial resources are limited.

PMID 17958626  Int J Dermatol. 2007 Oct;46 Suppl 2:23-8. doi: 10.1111/・・・
著者: A Alomar, S Videla, J Delgadillo, I Gich, I Izquierdo, J Forn
雑誌名: Dermatology. 1995;190(4):295-300.
Abstract/Text BACKGROUND: Flutrimazole is a new imidazole derivate. Its antifungal activity has been demonstrated in in vivo and in vitro studies to be comparable to that of clotrimazole and higher than bifonazole.
AIM: To compare the efficacy and tolerability of flutrimazole cream 1% with a reference drug, bifonazole, in the treatment of dermatomycoses, eligible for topical treatment exclusively.
METHODS: A multicentre, double-blind, randomized, parallel-group clinical trial was conducted. Patients with clinically and mycologically (KHO and/or culture) diagnosed fungal infection of the skin were included in this study and were randomized into two treatment groups: 1% flutrimazole or 1% bifonazole, applied to the affected area (target lesion) once a day. The principal criterion of efficacy, 'cure', was based on clinical and mycological assessment.
RESULTS: Four hundred and forty-nine patients were included in the study (228 flutrimazole, 221 bifonazole). 'Intention-to-treat' analysis of the data showed a difference between the treatments in terms of the rate of cure (clinical and mycological) after 4 weeks: 73% in the flutrimazole group and 65% in the bifonazole group (p = 0.05). From a safety point of view, flutrimazole and bifonazole were well tolerated, and the overall incidence of adverse effects (mainly mild local effects like irritation or burning sensation) was 5%.
CONCLUSIONS: One percent flutrimazole applied topically once a day in the treatment of fungal infections of the skin presents a better efficacy than bifonazole and a good tolerability.

PMID 7655109  Dermatology. 1995;190(4):295-300.
著者: M V Shelanski, S B Phillips, C E Potts
雑誌名: Int J Dermatol. 1996 Feb;35(2):137-40.
Abstract/Text BACKGROUND: Reports of purported sensitization reactions to widely used prescription dermatologicals have raised questions concerning the clinical significance of these reports. The current study was designed to compare irritant and sensitization potentials of such marketed products and to evaluate the risks involved in their usage.
METHODS: One hundred and eight healthy adult volunteers were evaluated for primary irritation and hypersensitivity following application under a double-blind paradigm of eight leading prescription dermatologic products and the vehicle cream of one product according to an intensified version of the Shelanski and Shelanski "Repeated Insult Patch Test."
RESULTS: No clinically significant irritant or sensitization reactions were associated with applications of topical formulations containing clobetasol propionate, doxepin hydrochloride, metronidazole, mupirocin, oxiconazole nitrate, and terbinafine hydrochloride. The doxepin hydrochloride cream vehicle was also found to be nonirritating and nonsensitizing. Both calcipotriene and ketoconazole were moderate irritants and possible sensitization reactions were also associated with ketoconazole.
CONCLUSION: Although every topically applied chemical has the potential to cause an adverse response in some individuals, the data obtained in this study for eight commercially available prescription dermatologic products indicate that most are quite safe and have very low risks of clinically significant irritation or sensitization.

PMID 8850048  Int J Dermatol. 1996 Feb;35(2):137-40.
著者: U Budimulja, K Bramono, K S Urip, S Basuki, G Widodo, G Rapatz, C Paul
雑誌名: Mycoses. 2001;44(7-8):300-6.
Abstract/Text Duration of therapy is an important factor in determining patients' compliance in dermatomycosis. Terbinafine (Lamisil) is an allylamine antifungal agent. Its fungicidal properties against dermatophytes should allow physicians to reduce treatment duration without affecting the cure rate. This study was carried out to determine the efficacy and tolerability of terbinafine 1% cream, applied once daily for 7 days, in adult patients with tinea corporis/cruris. In a multicentre, randomized, double-blind, parallel-group study, patients with a clinical diagnosis of tinea corporis/cruris confirmed by microscopy and culture received treatment with either terbinafine 1% cream (n = 57) or placebo cream (n = 60). The patients applied the cream once daily for 7 days, and were then observed for a further 7 weeks. The efficacy was assessed at the end of the study by comparing the rates of mycological cure in the two treatment groups. Total clinical signs and symptoms scores, clinical response, and overall treatment efficacy were also measured and compared between the two groups. A 7-day once-daily course of terbinafine was significantly more effective than placebo in achieving and maintaining mycological cure (84.2 versus 23.3%, P< 0.001). Terbinafine was also significantly more effective than placebo in terms of clinical response, reduction in signs and symptoms scores, and overall efficacy. The short treatment regimen and the sustained high cure rate should contribute to making terbinafine a valuable treatment option in tinea corporis/cruris.

PMID 11714065  Mycoses. 2001;44(7-8):300-6.
著者: V Voravutinon
雑誌名: J Med Assoc Thai. 1993 Jul;76(7):388-93.
Abstract/Text Sixty-four patients with clinically and mycologically diagnosed tinea corporis and tinea cruris were randomly allocated to receive either 250 mg of oral terbinafine once daily or 500 mg of griseofulvin once daily for 2 wks. Patients in each group were well matched for age, gender, clinical features and type of dermatophytes. Clinical and mycological control tests (KOH wet mount and culture) were performed before treatment, at the end of treatment and 4 wks after stopping treatment. In the majority of cases, the infecting agent was identified as Trichophyton rubrum (53/64). The remainder comprised Trichophyton mentagrophytes (8/64) and Epidermophyton floccosum (3/64). After 2 wks of therapy, there was no significant difference in mycological response in the terbinafine group (90.3%) and griseofulvin group (80.7%). The clinical response in both groups was the same. At 6 wks' follow-up, the mycological cure in terbinafine and griseofulvin group was 87.1 and 54.8 per cent, respectively (P < 0.05). The clinical response of the terbinafine group was also significantly higher than in the griseofulvin group. A higher relapse rate was observed in the griseofulvin group than in the terbinafine group. No serious side effects were reported in either group. The result showed that oral terbinafine was more effective than oral griseofulvin in the treatment of tinea corporis or tinea cruris.

PMID 8089640  J Med Assoc Thai. 1993 Jul;76(7):388-93.
著者: D M Pariser, R J Pariser, G Ruoff, T L Ray
雑誌名: J Am Acad Dermatol. 1994 Aug;31(2 Pt 1):232-4.
Abstract/Text BACKGROUND: Tinea corporis and tinea cruris are usually treated with a topical antifungal agent unless the infection is unresponsive, involves an extensive area, is chronic, or is in a difficult-to-access area. In these cases oral antifungals are frequently used.
OBJECTIVE: This double-blind study was undertaken to determine whether a 2-week course of oral itraconazole would produce statistically significant clinical and mycologic improvement in the treatment of tinea corporis, tinea cruris, or both, over the results obtained with placebo. A second objective was to determine the safety of itraconazole, through routine measurements of serum chemistry profiles.
METHODS: Sixty-seven patients were entered into a double-blind, multicenter study to compare the clinical and mycologic effects of itraconazole, 100 mg daily (45 patients), and placebo (22 patients) on tinea corporis and/or tinea cruris. The duration of treatment was 2 weeks. The investigators assessed signs and symptoms and performed a potassium hydroxide examination and culture at baseline, at termination of therapy, and 2 weeks after completion of treatment.
RESULTS: Twenty-two (96%) of 23 evaluable patients in the itraconazole group had healed or markedly improved lesions, as compared with 5 of 13 (39%) in the placebo group (p < or = 0.01). Similarly, the condition in 13 of 23 patients (57%) in the itraconazole group was mycologically cleared at the end of treatment whereas this result occurred in only 2 (17%) of 12 patients in the placebo group (p = 0.02). The prevalence of adverse side effects was lower for the itraconazole-treated group (20%) than for the placebo-treated group (36%).
CONCLUSION: Itraconazole 100 mg once daily is an effective agent for the treatment of tinea cruris and tinea corporis.

PMID 8040406  J Am Acad Dermatol. 1994 Aug;31(2 Pt 1):232-4.
著者: D Panagiotidou, T Kousidou, G Chaidemenos, G Karakatsanis, A Kalogeropoulou, A Teknetzis, E Chatzopoulou, D Michailidis
雑誌名: J Int Med Res. 1992 Sep;20(5):392-400.
Abstract/Text A total of 40 patients with clinically and mycologically documented tinea corporis or tinea cruris were treated with 100 mg/day itraconazole (n = 19) or 500 mg/day griseofulvin (n = 21) for 15 days. Of the itraconazole-treated patients, 83.3% were healed or markedly improved, i.e. 'responders', after 15 days compared with 85.7% of griseofulvin-treated patients. At 15 days after the end of treatment, 88.2% of itraconazole- and 80.9% of griseofulvin-treated patients were classed as 'responders'. The mycological cure rate (both microscopy and culture negative) was generally lower than the clinical response rate. Both treatments were equally effective at the end of 15 days' treatment with 66.7% of patients cured, but itraconazole was superior to griseofulvin at the 15-day follow-up visit (77.8% of itraconazole-treated patients compared with 66.7% of griseofulvin-treated patients were cured). Both therapies were well tolerated; only one patient treated with itraconazole reported minor side-effects (dizziness, headache and gastro-intestinal disturbances). The results confirm those of earlier comparative trials and suggest that griseofulvin-treated patients are more at risk of relapse than are itraconazole-treated patients.

PMID 1333423  J Int Med Res. 1992 Sep;20(5):392-400.
著者: A Bourlond, J M Lachapelle, J Aussems, B Boyden, H Campaert, S Conincx, J Decroix, C Geeraerts, L Ghekiere, J Morias
雑誌名: Int J Dermatol. 1989 Jul-Aug;28(6):410-2.
Abstract/Text Seventy-eight patients with tinea corporis or tinea cruris participated in a double-blind study with either 100 mg itraconazole or 500 mg ultramicronized griseofulvin for 15 consecutive days. Clinical outcome was significantly in favor of itraconazole at completion of treatment (72% response rate vs. 51%) and at the follow-up visit (91% response vs. 64%). The most important difference between both treatments was the mycologic outcome, for which itraconazole showed a cure rate of 87% compared to 57% for griseofulvin 2 weeks after completion of therapy. It is suggested that 100 mg of itraconazole orally once daily is significantly more effective than 500 mg of griseofulvin once daily for 15 days in the treatment of glabrous skin infections. Both drugs were well tolerated.

PMID 2548967  Int J Dermatol. 1989 Jul-Aug;28(6):410-2.

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