Tinea versicolor koh test fungální infekce (Objednejte antifungální sprej OnycoSolve)

Tinea Corporis

Aka: Tinea Corporis , Tinea Circinata , Ringworm

Dermatology

Fungal Infections Chapter

From Related Chapters

II. Etiology

  1. Trichophyton rubrum
  2. Epidermophyton floccosum
  3. Trichophyton tonsurans
  4. Trichophyton mentagrophytes
  5. Microsporum canis

III. Risk Factors

  1. Immunocompromised patients
  2. Allergic dermatitis and other causes of disrupted skin
  3. Genetic predisposition

IV. Pathophysiology

  1. Infection
    1. Exposure to contaminated soil
    2. Exposure to infected people (e.g. Tinea Corporis Gladiatorum)
    3. Exposure to infected animals (e.g. dogs, cats, rabbits, rodents)
      1. Will appear on dog skin as red lesions with Alopecia and crusting
      2. Typically Microsporum canis
  2. Growth and transmission facilitating factors
    1. Warm and moist environments (showers and pools)
    2. Shared towels or clothing
  1. Location: Glabrous skin (excludes palms, soles, groin)
  2. Characteristics
    1. Round, erythematous, Scaling, pruritic Plaques
    2. Annular Lesion (hence the name Ringworm)
      1. Raised, advancing border
      2. Plaque with central clearing
        1. No central clearing after Corticosteroid use
    3. Postinflammatory pigmentation changes

VI. Precautions

  1. Widespread Ringworm suggests underlying disease
  1. Potassium Hydroxide (KOH 20%)
    1. Scrape from active border
  2. Chlorazol black
    1. Highlights fungal hyphae
  3. Fungal Culture
    1. Suspected dermatophyte infection despite negative KOH
    2. Dermatophyte testing medium (DTM)
  4. Biopsy
    1. PAS stain will show hyphae in Stratum Corneum

VIII. Differential Diagnosis

  1. See Annular Lesion
  2. Pityriasis Rosea (especially the herald patch)
  3. Nummular Eczema (Atopic Dermatitis)
  4. Drug allergy or Fixed Drug Eruption
  5. Guttate Psoriasis (annular Psoriasis)
  6. Erythema Annulare Centrifugum
  7. Erythema Multiforme
  8. Contact Dermatitis
  9. Discoid Lupus
  10. Bowen’s Disease
  11. Parapsoriasis
  12. Mycosis Fungoides (Cutaneous T Cell Lymphoma)
  13. Granuloma Annulare
  14. Secondary Syphilis
  15. Seborrheaic dermatitis

IX. Management

  1. Prevent re-infection (see pathophysiology above)
  2. Topical Antifungal applied twice daily for 2-3 weeks
    1. Technique
      1. Apply to infected and normal skin 2 cm beyond affected area
      2. Continue for 7 days after symptom resolution
    2. First line: Imidazoles (e.g. Clotrimazole)
    3. Refractory cases: Naftin, Lamisil, Loprox, Mentax
  3. Systemic Antifungal
    1. Indications
      1. Immunocompromised patient
      2. Disabling or widespread lesions
      3. Chronic infection
      4. Hyperkeratotic area involvement (palms or soles)
    2. Duration
      1. Start with 2-4 week course
      2. Consider extending prescription for additional 2-4 week course
    3. Preparations
      1. Terbinafine 250 mg orally daily
      2. Fluconazole 150 mg orally once per week
      3. Itraconazole (Sporanox)
      4. Griseofulvin 0.5-1.0 grams per day
      5. Ketoconazole 200 mg orally daily
        1. Indicated only for severe, refractory cases due to Ketoconazole hepatotoxicity
        2. If Ketoconazole is used, requires Liver Function Tests at baseline and again weekly

X. Complications

  1. Deep follicular Tinea Infection (Majocchi’s Granuloma)
    1. Complication of Topical Corticosteroid use
    2. More commonly affects women, and most often on legs

XI. References

  1. Gilbert (1999) Sanford Guide to Antimicrobials
  2. Andrews (2008) Am Fam Physician 77(10): 1415-20 [PubMed]
  3. Schwartz (2004) Lancet 364(9440):1173-82 [PubMed]
  4. Drake (1996) J Am Acad Dermatol 34(2 pt 1):282-6 [PubMed]
  5. Hsu (2001) Am Fam Physician 64(2):289-96 [PubMed]

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Ontology: Tinea (C0040247)

Tinea is the name of a group of diseases caused by a fungus. Types of tinea include ringworm, athlete’s foot and jock itch. These infections are usually not serious, but they can be uncomfortable. You can get them by touching an infected person, from damp surfaces such as shower floors, or even from a pet.

Symptoms depend on the affected area of the body:

  • Ringworm is a red skin rash that forms a ring around normal-looking skin. A worm doesn’t cause it.
  • Scalp ringworm causes itchy, red patches on your head. It can leave bald spots. It usually affects children.
  • Athlete’s foot causes itching, burning and cracked skin between your toes.
  • Jock itch causes an itchy, burning rash in your groin area.

Over-the-counter creams and powders will get rid of many tinea infections, particularly athlete’s foot and jock itch. Other cases require prescription medicine.

Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Tinea corporis (disorder) (C0040252)

Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Fungal Infections

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Dermatology – Fungal Infections Pages

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Pediatric Tinea Versicolor Workup

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Laboratory Studies

The diagnosis of tinea versicolor is usually made based on clinical examination findings; however, the diagnosis is easily confirmed with microscopic examination of scales soaked in 10-15% potassium hydroxide (KOH). See the images below.

Microscopic examination

Microscopic examination demonstrates the characteristic thick-walled spherical or oval yeast forms and coarse septate mycelium, often broken up into short filaments. This combination of mycelium strands and numerous spores is commonly referred to as “spaghetti and meatballs.”

Liquid blue ink, methylene blue, or Swartz-Medrik stain can be added to the KOH preparation for better visualization of the causative organism.

Scales may also be removed using clear adhesive tape; they are then directly examined. The tape must be clear and is pressed several times over involved areas of skin. The tape is then lightly pressed, sticky side down, onto a microscope slide. A small drop of methylene blue or other appropriate stain is placed at the edge of the tape and allowed to run between the tape and the glass slide. Spores, often in grapelike clumps, and mycelium are easily seen. See the image below.

A few reports in literature have recently stated that 1% Chicago Sky Blue 6B (CSB) staining with 10% KOH is a new promising contrast diagnostic method for pityriasis versicolor, with 100% of sensitivity compared with 60.9% in culture. [6]

M furfur is a dimorphic lipophilic organism, which is cultured only in media enriched with C12-sized to C14-sized fatty acids. It is not a dermatophyte, does not grow on DTM, and does not respond to griseofulvin therapy.

If inoculated into lipid-rich media, the scales of tinea versicolor show spherical yeasts that produce the mycelial phase of the normal flora yeast P orbiculare. Scales that show mycelium and clusters of oval yeasts on direct microscopy grow P ovale on culture.

Colonization by M furfur is especially dense in the scalp, the upper trunk, and the flexures. In patients with clinical disease, the organism occurs in both the filamentous (hyphal) and the yeast (spore) stage forms.

Imaging Studies

The disease does not require any imaging studies.

Other Tests

Wood lamp evaluation

Pityriasis versicolor showe blue-green fluorescence of macular dyschromic lesions if irradiated by ultraviolet light with wavelength of approximately 365 nm (black light). However, the test findings may be negative in individuals on antimycotic therapy of those who have recently showered because the fluorescent is water soluble. [7]

Histologic Findings

The characteristic histological changes include hyperkeratosis, parakeratosis, and slight acanthosis with a mild perivascular inflammatory infiltrate in the upper dermis. The organism is usually present in the upper layers of the stratum corneum, and electron microscopy reveals invasion between and within the keratinized cells.

M furfur is detected by hematoxylin and eosin (H and E) stain alone, although periodic acid-Schiff (PAS) or methenamine-silver staining facilitates detection.

References

Dourmishev AL. Pityriasis versicolor. Iliev B, Mitov G, Radev M. Infectology. Academic publishing house; 2001. 812-3.

Schmidt A. Malassezia furfur: a fungus belonging to the physiological skin flora and its relevance in skin disorders. Cutis. 1997 Jan. 59(1):21-4. [Medline].

Nakabayashi A, Sei Y, Guillot J. Identification of Malassezia species isolated from patients with seborrhoeic dermatitis, atopic dermatitis, pityriasis versicolor and normal subjects. Med Mycol. 2000 Oct. 38(5):337-41. [Medline].

Levy JM, Magro C. Atrophying pityriasis versicolor as an idiosyncratic T cell-mediated response to Malassezia: A case series. J Am Acad Dermatol. 2017 Apr. 76(4):730-735. [Medline].

Day T, Scurry J. Vulvar pityriasis versicolor in an immunocompetent woman. J Low Genit Tract Dis. J Low Genit Tract Dis. 2014 Jul;. 18(3):e71-3. [Medline].

Lodha N, Poojary SA. A Novel Contrast Stain for the Rapid Diagnosis of Pityriasis Versicolor: A Comparison of Chicago Sky Blue 6B Stain, Potassium Hydroxide Mount and Culture. Indian J Dermatol. 2015 Jul-Aug. 60(4):340-4. [Medline]. [Full Text].

Wigger-Alberti W, Elsner P. Fluorescence with Wood’s light. Current applications in dermatologic diagnosis, therapy follow-up and prevention. Hautarzt. 1997 Aug. 48(8):523-7. [Medline].

[Guideline] Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for superficial mycotic infections of the skin: Pityriasis (tinea) versicolor. Guidelines/Outcomes Committee. American Academy of Dermatology. J Am Acad Dermatol. 1996 Feb. 34(2 Pt 1):287-9. [Medline].

Muhammad N, Kamal M, Islam T, Islam N, Shafiquzzaman M. A study to evaluate the efficacy and safety of oral fluconazole in the treatment of tinea versicolor. Mymensingh Med J. 2009 Jan. 18(1):31-5. [Medline].

Rosen T. Mycological Considerations in the Topical Treatment of Superficial Fungal Infections. J Drugs Dermatol. 2016 Feb. 15 (2 Suppl):s49-55. [Medline].

Cantrell WC, Elewksi BE. Can pityriasis versicolor be treated with 2% ketoconazole foam?. J Drugs Dermatol. 2014 Jul. 13(7):855-9. [Medline].

Gupta AK, Lyons DC. Pityriasis versicolor: an update on pharmacological treatment options. Expert Opin Pharmacother. 2014 Aug. 15(12):1707-13. [Medline].

Gupta AK, Lane D, Paquet M. Systematic review of systemic treatments for tinea versicolor and evidence-based dosing regimen recommendations. J Cutan Med Surg. 2014 Mar-Apr. 18(2):79-90. [Medline].

Neamsuvan O, Bunmee P. A survey of herbal weeds for treating skin disorders from Southern Thailand: Songkhla and Krabi Province. J Ethnopharmacol. 2016 Dec 4. 193:574-585. [Medline].

Gobbato AA, Babadópulos T, Gobbato CA, Ilha Jde O, Gagliano-Jucá T, De Nucci G. A randomized double-blind, non-inferiority Phase II trial, comparing dapaconazole tosylate 2% cream with ketoconazole 2% cream in the treatment of Pityriasis versicolor. Expert Opin Investig Drugs. 2015. 24 (11):1399-407. [Medline].

Badri T, Hammami H, Bzioueche N, Zouari B, Mokhtar I. Comparative clinical trial: fluconazole alone or associated with topical ketoconazole in the treatment of pityriasis versicolor. Tunis Med. 2016 Feb. 94 (2):107-11. [Medline].

Tsunemi Y. Oral Antifungal Drugs in the Treatment of Dermatomycosis. Med Mycol J. 2016. 57 (2):J71-5. [Medline].

Contributor Information and Disclosures

Lyubomir A Dourmishev, MD, PhD Associate Professor, Department of Dermatology and Venereology, Medical University of Sofia, Bulgaria

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Kevin P Connelly, DO Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University School of Medicine; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center

Tinea Versicolor Workup

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Laboratory Studies

The clinical presentation of tinea versicolor is distinctive, and the diagnosis is often made without any laboratory documentation.

The ultraviolet black light (Wood lamp) can be used to demonstrate the coppery-orange fluorescence of tinea versicolor. However, in some cases, the lesions appear darker than the unaffected skin under the Wood lamp, but they do not fluoresce.

The diagnosis is usually confirmed by potassium hydroxide (KOH) examination, which demonstrates the characteristic short, cigar-butt hyphae that are present in the diseased state. The KOH finding of spores with short mycelium has been referred to as the spaghetti and meatballs or the bacon and eggs sign of tinea versicolor. For better visualization, ink blue stain, Parker ink, methylene blue stain, or Swartz-Medrik stain can be added to the KOH preparation. Contrast stain containing 1% Chicago sky blue 6B and 8% KOH (as the clearing agent) achieves the greatest sensitivity and specificity. [26]

Special media are required for culture. Because the diagnosis is usually clinically suspected and can be confirmed with a KOH preparation, cultures are rarely obtained.

With blood examination, no definitive deficiencies of normal antibodies or complement are present in patients with tinea versicolor, but research continues in this area. For example, although individuals who are affected reveal no specific antibody levels above those of age-matched controls, M furfur antigens do elicit a specific immunoglobulin G response in patients with seborrheic dermatitis and tinea versicolor detected by enzyme-linked immunosorbent assay and Western blotting assays. M furfur does induce immunoglobulin A, immunoglobulin G, and immunoglobulin M antibodies, and it can activate complement via both the alternate pathway and the classical pathway.

Various studies have found defects in lymphokine production, natural killer T cells, decreased phytohemagglutinin and concanavalin A stimulation, interleukin 1, interleukin 10, and interferon gamma production by lymphocytes in patients.

Although these tests do not suggest an immunologic disorder, they do suggest a reduced body response to the specific fungal elements that produce tinea versicolor. Further assessment is warranted.

Histologic Findings

The organism that causes tinea versicolor is localized to the stratum corneum. M furfur can be detected by hematoxylin and eosin (H&E) alone, although periodic acid-Schiff (PAS) or methenamine silver staining are more confirmatory. On rare occurrences, the organism can approach the stratum granulosum, and it can even be found inside keratinocytes. [27] The epidermis reveals mild hyperkeratosis and acanthosis, and a mild perivascular infiltrate is present in the dermis. An acanthosis nigricans–like epidermal change is noted in the papular variety, with dilated blood vessels observed in erythematous lesions.

References

Crespo-Erchiga V, Florencio VD. Malassezia yeasts and pityriasis versicolor. Curr Opin Infect Dis. 2006 Apr. 19(2):139-47. [Medline].

Gaitanis G, Velegraki A, Alexopoulos EC, Chasapi V, Tsigonia A, Katsambas A. Distribution of Malassezia species in pityriasis versicolor and seborrhoeic dermatitis in Greece. Typing of the major pityriasis versicolor isolate M. globosa. Br J Dermatol. 2006 May. 154(5):854-9. [Medline].

Morishita N, Sei Y, Sugita T. Molecular analysis of malassezia microflora from patients with pityriasis versicolor. Mycopathologia. 2006 Feb. 161(2):61-5. [Medline].

Rincon S, Celis A, Sopo L, Motta A, Cepero de Garcia MC. Malassezia yeast species isolated from patients with dermatologic lesions. Biomedica. 2005 Jun. 25(2):189-95. [Medline].

Krisanty RI, Bramono K, Made Wisnu I. Identification of Malassezia species from pityriasis versicolor in Indonesia and its relationship with clinical characteristics. Mycoses. 2009 May. 52(3):257-62. [Medline].

Prohic A, Jovovic Sadikovic T, Krupalija-Fazlic M, Kuskunovic-Vlahovljak S. Malassezia species in healthy skin and in dermatological conditions. Int J Dermatol. 2016 May. 55 (5):494-504. [Medline].

Nakabayashi A, Sei Y, Guillot J. Identification of Malassezia species isolated from patients with seborrhoeic dermatitis, atopic dermatitis, pityriasis versicolor and normal subjects. Med Mycol. 2000 Oct. 38 (5):337-41. [Medline].

Tarazooie B, Kordbacheh P, Zaini F, Zomorodian K, Saadat F, Zeraati H, et al. Study of the distribution of Malassezia species in patients with pityriasis versicolor and healthy individuals in Tehran, Iran. BMC Dermatol. 2004 May 1. 4:5. [Medline].

Blaes AH, Cavert WP, Morrison VA. Malassezia: is it a pulmonary pathogen in the stem cell transplant population?. Transplant Infectious Disease. August, 2009. 11:313-317. [Medline].

Muhammad N, Kamal M, Islam T, Islam N, Shafiquzzaman M. A study to evaluate the efficacy and safety of oral fluconazole in the treatment of tinea versicolor. Mymensingh Med J. 2009 Jan. 18(1):31-5. [Medline].

He SM, Du WD, Yang S, et al. The genetic epidemiology of tinea versicolor in China. Mycoses. 2008 Jan. 51(1):55-62. [Medline].

Burkhart CG, Dvorak N, Stockard H. An unusual case of tinea versicolor in an immunosuppressed patient. Cutis. 1981. 27(1):56-8. [Medline].

Gulec AT, Demirbilek M, Seckin D, et al. Superficial fungal infections in 102 renal transplant recipients: a case-control study. J Am Acad Dermatol. 2003 Aug. 49(2):187-92. [Medline].

Mendez-Tovar LJ. Pathogenesis of dermatophytosis and tinea versicolor. Clinics in Dermatology. 2010. 28:185-188. [Medline].

Fungal Diseases. Bolognia J, Jorizzo JL, Schaffer JV, eds. Dermatology. 3rd ed. Philadelphia, Pa: Elsevier Saunders; 2012. Vol 2: 1251-55.

Kilic M, Oguztuzum S, Karadag S, Cakir E, Aydin M, Ozturk L. Expression of GSTM4 and GSTT1 in patients with Tinea versicolor, Tinea inguinalis, and Tinea pedis infections: a preliminary study. Clinical Dermatology. 2011. 36:590-594. [Medline].

Haiduk J, Treudler R, Ziemer M. Atrophying tinea versicolor with epidermal atrophy. J Dtsch Dermatol Ges. 2016 Jul. 14 (7):740-3. [Medline].

Cullingham K, Hull PR. Atrophying pityriasis versicolor. CMAJ. 2014 Jul 8. 186 (10):776. [Medline].

Tatnall FM, Rycroft RJ. Pityriasis versicolor with cutaneous atrophy induced by topical steroid application. Clin Exp Dermatol. 1985 May. 10 (3):258-61. [Medline].

Crowson AN, Magro CM. Atrophying tinea versicolor: a clinical and histological study of 12 patients. Int J Dermatol. 2003 Dec. 42 (12):928-32. [Medline].

Levy JM, Magro C. Atrophying pityriasis versicolor as an idiosyncratic T cell-mediated response to Malassezia: A case series. J Am Acad Dermatol. 2016 Nov 2. [Medline].

Zhou H, Tang XH, De Han J, Chen MK. Dermoscopy as an ancillary tool for the diagnosis of pityriasis versicolor. J Am Acad Dermatol. 2015 Dec. 73 (6):e205-6. [Medline].

Errichetti E, Stinco G. Dermoscopy in General Dermatology: A Practical Overview. Dermatol Ther (Heidelb). 2016 Dec. 6 (4):471-507. [Medline].

Suwattee P, Cham PM, Solomon RK, Kaye VN. Tinea versicolor with interface dermatitis. J Cutan Pathol. 2009 Feb. 36(2):285-6. [Medline].

Romano C, Maritati E, Ghilardi A, Miracco C, Mancianti F. A case of pityriasis versicolor atrophicans. Mycoses. 2005 Nov. 48 (6):439-41. [Medline].

Lim SL, Lim CS. New contrast stain for the rapid diagnosis of pityriasis versicolor. Arch Dermatol. 2008 Aug. 144(8):1058-9. [Medline].

Janaki C, Sentamilselvi G, Janaki VR, Boopalraj JM. Unusual observations in the histology of Pityriasis versicolor. Mycopathologia. 1997. 139(2):71-4. [Medline].

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Gupta AK, Skinner AR. Ciclopirox for the treatment of superficial fungal infections: a review. Int J Dermatol. 2003 Sep. 42 Suppl 1:3-9. [Medline].

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Wahab MA, Ali ME, Rahman MH, Chowdhury SA, Monamie NS, Sultana N, et al. Single dose (400mg) versus 7 day (200mg) daily dose itraconazole in the treatment of tinea versicolor: a randomized clinical trial. Mymensingh Med J. 2010 Jan. 19(1):72-6. [Medline].

Faergemann J, Todd G, Pather S, et al. A double-blind, randomized, placebo-controlled, dose-finding study of oral pramiconazole in the treatment of pityriasis versicolor. J Am Acad Dermatol. 2009 Dec. 61(6):971-6. [Medline].

Gupta AK, Lane D, Paquet M. Systematic review of systemic treatments for tinea versicolor and evidence-based dosing regimen recommendations. J Cutan Med Surg. 2014 Mar-Apr. 18(2):79-90. [Medline].

Mellen LA, Vallee J, Feldman SR, Fleischer AB Jr. Treatment of pityriasis versicolor in the United States. J Dermatolog Treat. 2004 Jun. 15(3):189-92. [Medline].

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Faergemann J, Gupta AK, Al Mofadi A, Abanami A, Shareaah AA, Marynissen G. Efficacy of itraconazole in the prophylactic treatment of pityriasis (tinea) versicolor. Arch Dermatol. 2002 Jan. 138(1):69-73. [Medline].

Kim YJ, Kim YC. Successful treatment of pityriasis versicolor with 5-aminolevulinic acid photodynamic therapy. Arch Dermatol. 2007 Sep. 143(9):1218-20. [Medline].

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Fernandez-Nava HD, Laya-Cuadra B, Tianco EA. Comparison of single dose 400 mg versus 10-day 200 mg daily dose ketoconazole in the treatment of tinea versicolor. Int J Dermatol. 1997 Jan. 36(1):64-6. [Medline].

Burkhart CG. Tinea versicolor. J Dermatol Allergy. 1983. 6:8-12.

Contributor Information and Disclosures

Lauren N Crouse The Brody School of Medicine at East Carolina University

Christopher Sayed, MD Clinical Assistant Professor of Dermatology, Clinician Educator, Director of Medical Student Education, Director of Hidradenitis Suppurativa Clinic, University of North Carolina at Chapel Hill School of Medicine

Craig N Burkhart, MD, MSBS Assistant Professor, Department of Dermatology, University of North Carolina at Chapel Hill School of Medicine

Michael J Wells, MD, FAAD Dermatologic/Mohs Surgeon, The Surgery Center at Plano Dermatology

Edward F Chan, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Craig G Burkhart, MD, MPH Clinical Professor, Department of Medicine, Medical College of Ohio; Clinical Assistant Professor, Department of Medicine, Ohio University College of Osteopathic Medicine

Kathryn Schwarzenberger, MD Associate Professor of Medicine, Division of Dermatology, University of Vermont College of Medicine; Consulting Staff, Division of Dermatology, Fletcher Allen Health Care

Lorie Gottwald, MD Chief, Division of Dermatology, Associate Professor, Department of Internal Medicine, Medical College of Ohio at Toledo

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Eric Zynda eazynda@gmail.com, is a liar and cheater to his wife of 8 years he lives in Rosemount Minnesota, got fired from his job for inappropriate

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