Background: Data about relapses of onychomycosis after treatment with the new systemic antifungals vary among the different studies, with figures ranging from 3 to 20% for terbinafine and from 21 to 27% for itraconazole, depending on the follow-up duration. Objective: To determine the prevalence of relapses of onychomycosis cured by terbinafine compared with that of onychomycosis cured by itraconazole. Methods: We followed up 47 patients whose toenail onychomycosis had been mycologically cured in an open randomized study comparing intermittent itraconazole treatment with continuous terbinafine treatment and intermittent terbinafine therapy. Patients were examined every 3 months for up to 3 years after the end of therapy. At each visit clinical and mycologic (direct microscopy and cultures) evaluations were performed. Results: Eight of the 36 patients (22.2%) who completed the study had a relapse of onychomycosis during the follow-up period, including 2 patients of the terbinafine 250 mg group, 2 patients of the terbinafine 500 mg group and 4 patients in the itraconazole 400 mg group. As the original infection, the relapse was caused in all cases by Trichophyton rubrum. Conclusions: This study shows that 22.2% of patients with onychomycosis successfully treated with systemic antifungals experienced a relapse. The relapse rate increased from 8.3% at month 12 to 19.4% at month 24 and to 22.2% at month 36. Relapses were more common in patients treated with pulse itraconazole (4/11) than in patients treated with continuous (2/12) or intermittent (2/13) terbinafine. Statistical analysis did not reveal any significant difference between relapse rates in the three groups.

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Dear Editor, SARS-Cov-2 infection has been associated with many dermatologic manifestations, both in symptomatic and asymptomatic patients. 1-3 A 54-year-old Caucasian woman was referred to us because of the rapid-onset of multiple patches of alopecia on her scalp. The patient had been diagnosed with SARS-Cov-2 infection 2 months earlier, thanks to nasal and throat swabs and chest computer tomography. She had been treated for 7 days with hydroxychloroquine therapy, 200 mg twice a day, started 7 days after the onset of mild respiratory symptoms. At the time of our visit the patient was in good health condition and was apyretic. She had recovered from SARS-COv-2 infection 2 weeks before, according to two consecutive negative tests obtained by nasal and throat swabs. Physical examination revealed three asymptomatic patches of alopecia on the right temporo-parietal area of her scalp (Figure 1). The surface of the patches was smooth, without signs of inflammation, and pull test resulted positive from the edges of the patches. Dermatoscopy showed the presence of black dots, yellow dots and vellus hair, allowing the diagnosis of alopecia areata (AA) (Figure 2).

Six cases of Scopulariopsis onychomycosis, including four patients with onychomycosis exclusively caused by Scopulariopsis brevicaulis and two patients with a mixed nail infection (S. brevicaulis + Tricophyton rubrum and S. brevicaulis + T. interdigitale), are reported. Four patients presented with a typical distal subungual onychomycosis characterized by subungual hyperkeratosis and onycholysis of the distal nail plate. In two patients, Scopulariopsis infection produced a total dystrophic onychomycosis associated with painful periungual inflammation. Three patients were treated with four pulses of itraconazole, 400 mg daily for 1 week a month, and three patients with terbinafine, 250 mg daily for 4 months. The mycological examination 8 months after discontinuation of treatment showed that one patient was mycologically cured whereas the remaining five patients still carried S. brevicaulis in their nails. The clinical examination at the end of the follow-up period showed a complete cure of the nail abnormalities in only one patient.