AIDS Treatment News #161, October 16, 1992
John S. James
We asked Dr. Conant to describe his use of the drug, and the San Francisco trial he is planning with the developer, Janssen Pharmaceutica.
MC: "Eosinophilic folliculitis is an unexplained inflammatory infiltrate around the hair follicles in the skin, which instead of just having nutrophils and lymphocytes at the follicle, also has large numbers of eosinophils [a kind of immune-system cell], suggesting that this condition may be an allergic reaction to some organism in the skin. A number of researchers have looked for an organism which causes the condition, but nothing has been found consistently.
"In the past, what has been used to treat eosinophilic folliculitis has been low doses of ultraviolet light, just enough to cause a tan. Nobody knows why this works. High-dose cortisone can also relieve the condition; but cortisone is immunosuppressive, so it should be avoided if possible. Various topical medicines have also been tried, none with much benefit.
"Last year physicians in Scotland reported that when patients were treated with itraconazole [for other purposes], they had seen the itching stop. I treated a few patients and found that was true; I also tried fluconazole, a similar drug, and ketoconazole for eosinophilic folliculitis, and they have not been beneficial. We have now applied for investigational new drug approval to test itraconazole in a series of patients, to see if this observation can be confirmed scientifically.
"If this drug does in fact work, then either it is effective against some organism which is not susceptible to the other drugs, or it might be working through some other mechanism in the hair follicle."
JJ: Itraconazole has been reported to concentrate in the skin.
MC: "That's right. One way we expect that this drug might be used, now that it is approved, is to treat someone with a fungus in their nail for a month or so, then stop the drug since it may stay there and continue to work. If this theory works, you might only have to treat the patient for a month every three or four months. The advantage is that you would not constantly expose the liver to the drug.
"Itraconazole is also important because it has very good activity against aspergillosis, a rare fungal infection. Fluconazole and ketoconazole have some activity in this disease, but less. Now that the drug is approved, physicians will learn quickly what conditions it may be effective for where fluconazole and ketoconazole have been less useful.
"Itraconazole, like ketoconazole, requires stomach acidity to be absorbed; that is not true of fluconazole. And many patients with less than 100 T-helper cells do not make enough acid in the stomach. In our study, which will start next month, we will measure itraconazole after oral administration with and without a diet Coke given at the same time. Theoretically that drink should put enough acid in the stomach so that the drug will be absorbed. But we have to demonstrate that this really will work.
"If people have eosinophilic folliculitis and would like to work with us in the trial to show whether itraconazole is effective, they should call Christopher King, 415/661-2614. He will be administering this study."
JJ: For people who are not in the area or do not want to join the trial, how have you been treating patients in the past?
MC: "The dose used in Europe was 300 mg per day of itraconazole for about a month.
"Patients should have their liver functions followed. Liver toxicity has been reported less with itraconazole than with ketoconazole, but it can occur."
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