Is it possible for someone who has an immunodepression to get rid of tinea barbae? I most likely got it from a cat about a year ago, and I was treated with miconazole nitrate cream and oral Diflucan for five weeks. The tinea seemed to be gone, but after a few months it started coming back. I tried to push it away each time with the cream, but now there's an area of my face with no more beard, very near where the tinea usually appeared. Will the beard grow again? And how can I make this go away forever? I've started with Diflucan again every other day. How long do I need to take this?

T.B.

Tinea barbae is an infection of the beard and neck area in men, caused by species of dermatophytes (skin fungi). Dermatophyte infections are superficial fungal infections of the skin that include athlete's foot, jock itch, and ringworm of the body and scalp. Facial infections can be quite localized, and can be pustular (pus-filled), looking a lot like small boils. All of these infections except scalp ringworm can be treated with a topical agent (such as a cream or ointment). There are a variety of effective agents, including clotrimazole (Lotrimin and others) and miconazole (Monistat and others). Scalp ringworm requires oral therapy.

In general, facial infections respond well to topical agents. However, in some people, especially those with immune disorders, drug treatment may fail to clear up the infection, and relapses can occur. I wonder if your immunodepression is from HIV, the virus that causes AIDS, because patients with HIV are at special risk of infection that is severe or refractory (unresponsive to treatment). In such cases, oral therapy is often necessary for cure. Fluconazole (Diflucan) is effective, but two other therapies have more support in the medical literature for cases of this sort. The first, and the one with which I have been most successful, is terbinafine (Lamisil). This is the same drug that is commonly used in fungal nail infections. When terbinafine is given daily for two weeks, the cure rate is quite high. I would strongly consider this choice in your case. This drug is very well tolerated and quite safe, in most cases.

Another option is itraconazole (Sporanox), which is also commonly given for nail infections. One potential problem with this choice is that it interacts with several drugs given for HIV. If you are not on any of these medications, however, then itraconazole is also a good option for you. I would try terbinafine first, only because I have had good success with it. Then, if this fails, I would consider a longer course, perhaps four two six weeks. In addition, I would ensure that your immune suppression is maximally treated, which will certainly improve your chances of cure. Then, if the infection is still a problem, you can consider chronic (long-term) suppressive treatment, possibly once-weekly therapy. Hair loss from the infection usually is only temporary, so it is likely that your beard will grow back.