Fungal infections of skin [compatibility mode]

Management of
Common
Fungal Skin Infections

• Superficial fungal infections of
the skin are one of the most
common dermatologic
conditions seen in clinical
practice.

Fungi: Common Groups

1. Dermatophytes: Superficial Ring
worm type
2. Candida Albacans: Yeast infection
3. Pityrosporium: Yeast, present in
normal flora of skin, esp. scalp &
trunk.

CLASSIFICATION OF
FUNGAL INFECTION
1.Superficial
2.Cutaneous
3.Subcutaneous
4.Systemic
5.Opportunistic

1. Superficial mycoses
- Pityriasis versicolor – pigmented lesion
on torso (trunk of the human body). ( Dubo? )
- Tinea nigra – gray to black macular lesion
on palms.
- Black piedra – dark gritty deposits on hair.
- White piedra – soft whitish granules along
hair shaft.
- All diagnosed by microscopy and easily
treated by topical preparation.

2. Cutaneous infections

• Infections of skin and its appendages
(nails, hair)
• 20 Spp. of dermatophytes cause
ringworm.

3. Subcutaneous mycoses
-Subcutaneous infections, over 35 spp.
Produce chronic inflammatory disease
of subcutaneous tissue & lymphatics,
e.g. sporotrichosis (Ulcerated lesion at
site of inculasion followed by multiple
nodules)

4. Systemic fungal infections
- Uncommon: if Natural immunity is high
- Physiologic barriers include:
- Skin and mucus membranes
- Tissue temperature: fungi grow better at
less than 37°C

5. Opportunistic Mycoses
- Do not normally cause disease in healthy people.
- Cause disease in immuno-compromised people.
- Weakened immune function may occure due to:
▪ Inherited immunodeficiency disease
▪ Drugs that suppress immune system:
cancer chemotherapy, corticosteroids, drugs
to prevent organ transplant Rejection.
▪ Radiation therapy
▪ Infection (HIV)
▪ Cancer, diabetes, advanced age and mal-nutrition.

Most common opportunistic mycotic
infections: (commonly seen in PLWHA)
1. Candidiasis
2. Aspergillosis
3. Cryptococcosis
4. Zygomycosis/mucormycosis
5. Pneumocystis carinii

Superficial Fungal
Infections

• Tinea infections

TINEA Infection

• T.Corporis- ringworm of body
• T.Cruris- groin
• T.Pedis- foot
• T.Unguium- nail
• T.Capitis scalp

T.Corporis (ring of the body)
• Superficial skin infection
• Itchy
• Annular patch (ring shaped)
• Well defined edge
• Scaling more obvious at
edges(central clearing)

Fungal infections of skin [compatibility mode]

Tinea corporis – body ringworm

Tinea corporis

Tinea Corporis Tinea of the face

Psoriasis Tinea corporis(Scaly lesion)
(for differential diagnosis)

TineaManum (hand) Tinea Corporis

TINEA CRURIS (groin)

• Often assoc with T.pedis
• “Jock itch”
• Tight hot sweaty groin
e.g. athletes, obese
• Infection of groin,
genitalia, perinium

Tinea Pedis –
Athlete’s Foot Infection

Tinea Pedis
Clinical features
• Dermatitis
• Peeling
• Maceration
• Fissuring
Sites
Toe clefts

Tinea Unguium – Nail Infection

Tinea Unguium (nail)
1. Disto-lateral
1
subungual
onychomycosis
2. Superficial white 2
onychomycosis
3. Total dystrophic 3
onychomycosis

Regimes-Tinea Unguium
• TERBINAFINE
– Terbinafine250mg od

• ITRACONAZOLE
– Pulse rx Itraconazole - 1wk/mth 200mg bid
– Itraconazole 200mg od

• FLUCANAZOLE
– Fluconazole 150mg once weekly

TINEA CAPITIS - KERION

Ringworm of the scalp

Tinea Capitis

Gray Patch

Rx-Tinea Capitis
• MUST use oral Rx- prolonged course

–Griseofulvin-20mg/kg/od x 6-8/52
Terbinafine-250mg od x 4/52
–Flucanazole-50mg-150mg/wk x 4-6/52

Rx-Tinea Capitis
Adjunctive Measures

• Shampoo- antifungal/ antiseptic/antidandruff

• Antibiotics

• NO STEROIDS

Tinea Manuum
Dry hyperkeratotic
Palmer aspect
Dorsal aspect

Tinea Faciei
• Infection of the
skin of the face
excluded
moustache &beard
areas

Investigation:
- Microscopy of scrapings

KOH preparation and looking
for the fungal elements from
skin scraping, nail or hair.

Management

• General Measures
• Non-specific Keratolytics
-eg Whitfield’s ointment

Specific Antifungal Rx
• Griseofulvin
• Azoles-
-Imidazole eg ketoconazole (liver toxicity: oral prep)
topical preps
-Triazole eg itraconazole,fluconazole
• Allylamines eg terbinafine, naftifine

TOPICAL Rx
• Localized disease of skin
– extend rx for 3-5/7 after apparent cure
– 1% clotrimazole less effective

• Sprays & solutions
– tinea pedis /hairy areas

• Limited nail disease
– Batrafen nail lacquer

ORAL Rx
• Extensive disease

• Nail disease

• Tinea Capitis

For Systemic Fungal Infections
FDA approved drugs for empirical therapy
Drug Dosing regimen used in controlled trials
Ampho B 0.6 – 1.0 mg/kg/day (IV)
__________________________________________________
Liposomal 3 mg/kg/day (IV)
Ampho B
________________________________________________
Itraconazole 400 mg/day/or two days then 200 mg/d for
5-12 days (IV), followed by oral solution
400 mg/day for 14 days
__________________________________________________
Caspofungin 70 mg day 1, then 50 mg/daily

In BPKIHS D-OPD
COMMON FUNGAL PROBLEMS: All types
Rx: prescribed:
1. Hygiene teaching.
2. Antifungal:
a. Topical: Ketaconazole, Clotrimazole,
Butrinazole
b. Oral: Fluconazole, Ketaconazole, itrazole

7. Yeasts
• Pityrosporum.
• Candida.

• Ordinarily commensals.
• Can become pathogens under
favourable conditions.

Pityriasis Versicolor
• Asymptomatic
hypopigmented
scaly macules

• Chest, back, face

P.Versicolor
• Hyperpigmented

Like Dubi

8. Tinea Versicolor
(In Head)

Dandruff

Tinea Versicolor
Skin infection caused by a yeast
Warm and humid environment

Tinea Versicolor
S/S
- oval or irregularly shaped spots
- pale, dark , or pink in color
- sharp border
- itching, worsens with heating and
sweating
Tx
- Topical antifungal medications

Management
• Many Rx
• No Rx eradicates yeast permanently
• NONSPECIFIC
• Keratolytics
– whitfield onit, sulphur
• Antiseptics
– selenium sulphide, Na thiosulphate

Antifungal Rx
Azoles-oral/topical
• Ketoconazole 200mg od x7
• Itraconazole 200mg od x 7
• Fluconazole 300mg-400mg stat
• Terbinafine tabs for P.V

9. Candidiasis
o Candida sp- commensal of GIT
o Precipitating Factors
Endocrinopathy
Immunosuppression
Fe/Zn deficiency
Oral antibiotic Rx
o Oropharyngeal candidiasis is marker for AIDS

Candidiasis

• Oropharnygeal
• Candidal intertrigo-breasts, groin
• Chronic Paronychia - nail fold infection
• Vaginitis/balanitis

Risk Factors for Candidiasis:
▪ Post-operative status
▪ Cytotoxic cancer chemotherapy
▪ Antibiotic therapy
▪ Burns
▪ Drug abuse
▪ GI damage

Candidal Intertrigo
• Moist folds

• Erythematous patch
with satellite lesions

Management
• Rx underlying disorder
• Reduce moisture-
– Wt loss, cotton underwear
– Absorbent/antifungal powder eg Zeasorb AF
• Rx partner in recurrent genital candidiasis
• Rx-Nystatin
Azoles
• Oral antifungal (itraconazole): immune
suppressed

10. Chronic Paronychia
• Infection of nail fold
• Wet alkaline work
Excess manicuring
• Damage to cuticle
• Swelling of nail fold
(bolstering)
• Nail dystrophy

Chronic Paronychia
• Keep hands dry /Wear gloves
• Long term Rx
• Oral Azoles
• Antifungal solution-(high alcohol content)
• +/-Broad spectrum antibiotics-cover staph

Rx Summary
• Tinea capitis should be treated with
systemic therapy.
• Griseofulvin in a dose of 10-20 mg per
kg for six weeks to 8weeks is the first-
line treatment of Tinea capitis.
• Ketoconazole 2-4mg per kg for ten
days, itraconazole and terbinafine
(Lamisil) are good alternatives.

• Griseofulvin should be taken after fatty meal.
• Topical treatment can be added to decrease
the transmission and accelerate resolution.
• Whitefield ointment is preferred in the
absence of secondary bacterial infection.
• Other family members should also be
examined and treated.
• Small and single lesion can be treated with
topical agents. Clotrimazole 1%, ketoconazole
2%, meconazole 1%. BID for two weeks

• Systemic: ketoconazole 2-4mg per kg
of weight for 10 days. Itraconazole and
fluconazole are choices if available.
Griseofulvin is also effective for the
treatment of Tinea corporis.
• Topical anti fungal creams or
ointments applied regularly for 4 - 6
wks.

• Systemic treatments provide better skin
penetration than most topical preparations,
Itraconazole, terbinafine and griseofulvin
are good choices for oral therapy.
• Itraconazole and terbinafine are more
effective than griseofulvin. Once-weekly
dosing with fluconazole is another option,
especially in noncompliant patients.
• Personal hygiene (foot hygiene) is highly
advised.

Fungal infections of skin [compatibility mode]

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Fungal infections of skin [compatibility mode]