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Fungal infections of skin [compatibility mode]

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BP KOIRALA INSTITUTE OF HELATH SCIENCS,, NEPAL
BP KOIRALA INSTITUTE OF HELATH SCIENCS,, NEPAL

Superficial fungal infections of the skin are common. The document discusses the classification, presentation, and management of several common fungal infections including tinea infections, pityriasis versicolor, candidiasis, and chronic paronychia. For tinea capitis, oral griseofulvin or other systemic antifungals for 6-8 weeks are recommended. Topical antifungals are used for localized fungal infections while systemic antifungals like itraconazole or fluconazole are used for more extensive or resistant cases.

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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
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
Fungal infections of skin [compatibility mode]
Fungal infections of skin [compatibility mode]
Tinea Cruris – Jock Itch
Fungal infections of skin [compatibility mode]
Tinea Pedis – Athlete’s Foot Infection
Fungal infections of skin [compatibility mode]
Fungal infections of skin [compatibility mode]
Fungal infections of skin [compatibility mode]
Fungal infections of skin [compatibility mode]
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
T.Pedis
Fungal infections of skin [compatibility mode]
Fungal infections of skin [compatibility mode]
Fungal infections of skin [compatibility mode]
TINEA CAPITIS - KERION Ringworm of the scalp
TINEA CAPITIS – Black dot
Fungal infections of skin [compatibility mode]
Tinea Capitis
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
Other Fungal Infections
Tinea Manuum Dry hyperkeratotic Palmer aspect Dorsal aspect
Tinea Barbae
Tinea Faciei • Infection of the skin of the face excluded moustache &beard areas
Peri-oral dermatophytosis
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
Thank You
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
Pityriasis Versicolor
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.
Thank You

More Related Content

Fungal infections of skin [compatibility mode]

  • 1. Management of Common Fungal Skin Infections
  • 2. • Superficial fungal infections of the skin are one of the most common dermatologic conditions seen in clinical practice.
  • 3. 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.
  • 4. CLASSIFICATION OF FUNGAL INFECTION 1.Superficial 2.Cutaneous 3.Subcutaneous 4.Systemic 5.Opportunistic
  • 5. 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.
  • 6. 2. Cutaneous infections • Infections of skin and its appendages (nails, hair) • 20 Spp. of dermatophytes cause ringworm.
  • 7. 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)
  • 8. 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
  • 9. 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.
  • 10. Most common opportunistic mycotic infections: (commonly seen in PLWHA) 1. Candidiasis 2. Aspergillosis 3. Cryptococcosis 4. Zygomycosis/mucormycosis 5. Pneumocystis carinii
  • 11. Superficial Fungal Infections • Tinea infections
  • 12. TINEA Infection • T.Corporis- ringworm of body • T.Cruris- groin • T.Pedis- foot • T.Unguium- nail • T.Capitis scalp
  • 13. T.Corporis (ring of the body) • Superficial skin infection • Itchy • Annular patch (ring shaped) • Well defined edge • Scaling more obvious at edges(central clearing)
  • 16. Tinea corporis – body ringworm
  • 17. Tinea corporis Tinea Corporis Tinea of the face Psoriasis Tinea corporis(Scaly lesion) (for differential diagnosis) TineaManum (hand) Tinea Corporis
  • 18. TINEA CRURIS (groin) • Often assoc with T.pedis • “Jock itch” • Tight hot sweaty groin e.g. athletes, obese • Infection of groin, genitalia, perinium
  • 21. Tinea Cruris – Jock Itch
  • 23. Tinea Pedis – Athlete’s Foot Infection
  • 28. Tinea Pedis Clinical features • Dermatitis • Peeling • Maceration • Fissuring Sites Toe clefts
  • 29. Tinea Unguium – Nail Infection
  • 30. Tinea Unguium (nail) 1. Disto-lateral 1 subungual onychomycosis 2. Superficial white 2 onychomycosis 3. Total dystrophic 3 onychomycosis
  • 31. Regimes-Tinea Unguium • TERBINAFINE – Terbinafine250mg od • ITRACONAZOLE – Pulse rx Itraconazole - 1wk/mth 200mg bid – Itraconazole 200mg od • FLUCANAZOLE – Fluconazole 150mg once weekly
  • 36. TINEA CAPITIS - KERION Ringworm of the scalp
  • 37. TINEA CAPITIS – Black dot
  • 40. Tinea Capitis Gray Patch
  • 41. 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
  • 42. Rx-Tinea Capitis Adjunctive Measures • Shampoo- antifungal/ antiseptic/antidandruff • Antibiotics • NO STEROIDS
  • 44. Tinea Manuum Dry hyperkeratotic Palmer aspect Dorsal aspect
  • 46. Tinea Faciei • Infection of the skin of the face excluded moustache &beard areas
  • 48. Investigation: - Microscopy of scrapings KOH preparation and looking for the fungal elements from skin scraping, nail or hair.
  • 49. Management • General Measures • Non-specific Keratolytics -eg Whitfield’s ointment
  • 50. Specific Antifungal Rx • Griseofulvin • Azoles- -Imidazole eg ketoconazole (liver toxicity: oral prep) topical preps -Triazole eg itraconazole,fluconazole • Allylamines eg terbinafine, naftifine
  • 51. 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
  • 52. ORAL Rx • Extensive disease • Nail disease • Tinea Capitis
  • 53. 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
  • 54. 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
  • 56. 7. Yeasts • Pityrosporum. • Candida. • Ordinarily commensals. • Can become pathogens under favourable conditions.
  • 57. Pityriasis Versicolor • Asymptomatic hypopigmented scaly macules • Chest, back, face
  • 58. P.Versicolor • Hyperpigmented Like Dubi
  • 60. 8. Tinea Versicolor (In Head) Dandruff
  • 61. Tinea Versicolor Skin infection caused by a yeast Warm and humid environment
  • 62. 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
  • 63. Management • Many Rx • No Rx eradicates yeast permanently • NONSPECIFIC • Keratolytics – whitfield onit, sulphur • Antiseptics – selenium sulphide, Na thiosulphate
  • 64. Antifungal Rx Azoles-oral/topical • Ketoconazole 200mg od x7 • Itraconazole 200mg od x 7 • Fluconazole 300mg-400mg stat • Terbinafine tabs for P.V
  • 65. 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
  • 66. Candidiasis • Oropharnygeal • Candidal intertrigo-breasts, groin • Chronic Paronychia - nail fold infection • Vaginitis/balanitis
  • 67. Risk Factors for Candidiasis: ▪ Post-operative status ▪ Cytotoxic cancer chemotherapy ▪ Antibiotic therapy ▪ Burns ▪ Drug abuse ▪ GI damage
  • 68. Candidal Intertrigo • Moist folds • Erythematous patch with satellite lesions
  • 69. 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
  • 70. 10. Chronic Paronychia • Infection of nail fold • Wet alkaline work Excess manicuring • Damage to cuticle • Swelling of nail fold (bolstering) • Nail dystrophy
  • 71. Chronic Paronychia • Keep hands dry /Wear gloves • Long term Rx • Oral Azoles • Antifungal solution-(high alcohol content) • +/-Broad spectrum antibiotics-cover staph
  • 72. 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.
  • 73. • 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
  • 74. • 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.
  • 75. • 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.