Download - Fungal Infections of the Skin and Nails
![Page 1: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/1.jpg)
Fungal Infections of the Skin and Nails
Adam O. Goldstein, MD, MPH
Associate Professor
Department of Family Medicine
University of North Carolina at Chapel Hill
![Page 2: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/2.jpg)
Fungal Infections of the Skin and Nails
Objectives
1. To distinguish common fungal infections from similar appearing lesions; e.g. eczema
2. Improved dx of fungal lesions with a KOH scraping
3. Know at least 2 tx options for common fungal infections of the skin & nails
4. Know common errors in fungal dx and tx
5. Know when to suspect & how to dx ID reaction
![Page 3: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/3.jpg)
Sorry… but ….
![Page 4: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/4.jpg)
Superficial Fungal Infections
4.1 million visits -82% nondermatologists 3 types of fungi-dermatophytes: Epidermophyton
Trichophyton
Microsporum
Named by location Similar treatments; Varied presentations
![Page 5: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/5.jpg)
If they do this to food…..
![Page 6: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/6.jpg)
Superficial Fungal Infections
Common Denominator = Do KOH, Do KOH, Do KOH ..
Nondermatologists (34%) were more likely than dermatologists (5%) to prescribe combination products for the treatment of common fungal skin infections; savings = $10-25 million.
(Smith, JAAD,1998)
![Page 7: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/7.jpg)
KOH
![Page 8: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/8.jpg)
ID Reaction
Severe inflammatory skin reaction Immunologically mediated Appearance may be very different from
original lesion Fungal infections if severe enough may
provoke ID reaction. If you do not think about it, you will not diagnose it.
![Page 9: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/9.jpg)
ID Reaction
![Page 10: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/10.jpg)
Tinea capitis
Trichophyton or Microsporum species
Disease of children Exposure from other
children or pets Highly variable
presentation
![Page 11: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/11.jpg)
T. capitis
Primary lesions: plaques, papules, pustules or nodules
Secondary lesions: scale, alopecia, erythema, exudate and edema
Kerion: Severe T. capitis- inflamed, boggy nodule with hair loss
![Page 12: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/12.jpg)
Kerion
![Page 13: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/13.jpg)
T. capitis
Diagnosis Overdiagnosed in adults,
underdiagnosed in children Direct microscopic exam of hairs
looking for hyphae/spores Woods lamp: bright green
fluorescence in hair shafts d/t Microsporum infection (< 20% time)
Culture: If KOH is negative but strong clinical suspicion
![Page 14: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/14.jpg)
T. capitis
Differential Diagnosis Seborrheic dermatitis- rare in children, KOH - Cellulitis- may coexist, KOH - Alopecia areata-discrete, nonscaling areas
hair loss Syphilis- “mothball eaten” areas
![Page 15: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/15.jpg)
The diagnosis please…..
![Page 16: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/16.jpg)
T. capitis
Treatment Systemic therapy needed Griseofulvin at least 8 wks
(Or 2 wks beyond cure) Itraconazole- 3-5mg/kg/day
1x/week 3 weeks Fluconazole- 3-6 mg/kg children
(10, 40 ml) Terbinafine - 3-6mg/kg/day X 4
weeks
![Page 17: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/17.jpg)
Griseofulvin
Microsize 250, 500 mg tabs, 125 mg/5 cc susp
500-1000 mg/day adults 15-20 mg/kg/day children SE’s: photosensitivity, H/A, GI
upset, hypersensitivity, leukopenia Active only against dermatophytes, not
yeasts
![Page 18: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/18.jpg)
T. capitis
Patient education Compliance for 2 weeks beyond
“cure” to prevent relapse Look for sources of infections Clean contaminated objects Reassure caretakers that it may
take 1 month for improvement
![Page 19: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/19.jpg)
![Page 20: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/20.jpg)
Tinea barbae
Characteristics Inflammation in the
beard/hair Pseudofolliculitis Frequently “failed” antibiotics Positive S.Aureus culture does
not rule out T. barbae
![Page 21: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/21.jpg)
T. barbae
Diagnosis Nodular, boggy lesions
with exudate
Sinus tract formation Scarring if untreated KOH or culture may
confirm
![Page 22: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/22.jpg)
T. barbae
Differential diagnosis Bacterial folliculitis Pseudofolliculitis barbae Contact dermatitis Herpes Syphilis Acne Candida
![Page 23: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/23.jpg)
T. barbae
Treatment Griseofulvin 0.5-1 g/day Itraconazole or terbinafine for resistant
cases Local care
![Page 24: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/24.jpg)
Tinea corporis
Papules or plaques with erythema and scale Look for annular lesions with central clearing Well-demarcated edges
![Page 25: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/25.jpg)
T. corporis
Diagnosis KOH from leading edge Prior steroid use alters
response/appearance Majocchi’s granuloma:
pluck hairs for hyphae
![Page 26: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/26.jpg)
T. corporis vs. Majocchi’s granuloma
![Page 27: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/27.jpg)
T. corporis
Differential diagnosis Nummular eczema KOH neg Pityriasis rosea KOH neg, multiple
papules/plaques Psoriasis KOH neg, thick, silvery
scales Granuloma annulare KOH neg, no scale
Lyme disease KOH neg, no scale
![Page 28: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/28.jpg)
T. corporis: Differential diagnosis
![Page 29: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/29.jpg)
The diagnosis please...
Lichen simplex chronicus Nummular eczema
![Page 30: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/30.jpg)
T. corporis
Treatment Avoid “Lotrisone” type combos Topical agents for
mild/moderate disease Oral agents for
extensive/resistant disease Continue topical medication 7-
14 days beyond “cure”
![Page 31: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/31.jpg)
![Page 32: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/32.jpg)
Tinea cruris
Thrives in humid environments
Diagnosis: » Spares scrotum; » Pruritus & burning clues» Look for feet as possible
infection source» KOH + hyphae
![Page 33: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/33.jpg)
T.crurisDifferential Diagnosis: Candida Beefy red with poorly defined
borders Intertrigo KOH negative, irritant
dermatitis Erythrasma Asymmetric velvety patches,
Neg KOH Psoriasis Thick silvery scales,Neg
KOH Seb derm Borders less defined,
distribution different, Neg KOH
![Page 34: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/34.jpg)
T. cruris
Treatment Topical agents for 2-3
weeks Mild topical steroid for
inflammatory component Pruritus relief Look for infection source
![Page 35: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/35.jpg)
T. cruris
Patient education Use topical meds 7-14 days beyond cure Avoid prolonged topical steroids Avoid self-medicating preps Avoid baths and tight fitting underwear Use mild soaps or soap substitute Antifungal powders Keep area dry
![Page 36: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/36.jpg)
Tinea manus
Diagnosis: » Often unilateral, but
with bilateral feet» May have only scant
scaling, vesicles Differential Diagnosis:
Eczema, contact dermatitis Treatment: Topical agents
![Page 37: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/37.jpg)
The diagnosis is ...
![Page 38: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/38.jpg)
Tinea pedis
Diagnosis: – Extremely variable presentation– Be aware of id reaction and bacterial infection
![Page 39: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/39.jpg)
T. pedis
Differential Diagnosis: Eczema, Contact, Psoriasis, Keratolysis
Treatment and Patient Education: Limited: Antifungal creams X 1-4 weeks; Severe: Oral therapy
Griseofulvin 500 mg microsize bid X 4-8 weeksTerbinafine 250 mg/day X 2-6 weeks
![Page 40: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/40.jpg)
The diagnosis is …..
![Page 41: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/41.jpg)
![Page 42: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/42.jpg)
Tinea Versicolor
Diagnosis: macules, plaques; fine scale after scraping; KOH +
![Page 43: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/43.jpg)
Tinea Versicolor
Treatment: Limited disease: Topical agents
Widespread: Ketoconazole
200 mg X 2 one dose, repeat 1 week
(Not griseofulvin) Prevention and Patient Education:
Selenium sulfide 2.5% overnight 1X/month
![Page 44: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/44.jpg)
Candidiasis
Diagnosis: Beefy red lesions, satellite papules and pustules
Differential Dx: Tinea, Intertrigo
Treatment and Patient education : Topical antifungal creams
Oral therapy for extensive (not Griseofulvin)
Environmental: Zeasorb powder or Burow’s
Mild topical steroids
![Page 45: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/45.jpg)
The diagnosis is...
![Page 46: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/46.jpg)
Onychomycosis
![Page 47: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/47.jpg)
Onychomycosis
Why should we treat? (cosmetically disfiguring, painful, entry for cellulitis)
Diff Dx: Psoriasis, Lichen Planus, Trauma
Diagnosing vs. treating
![Page 48: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/48.jpg)
Diagnosis? Culture? Treatment?
![Page 49: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/49.jpg)
![Page 50: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/50.jpg)
CaseWhich of the following, if any, is
onychomycosis?
![Page 51: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/51.jpg)
Onychomycosis- treatments
8% Ciclopirox (Penlac) Topical therapy: FDA approved (2/00)
2 studies X 48 weeks:219 5.5% cc 6.5% ac vs. .9% placebo235 8.5% cc 12% ac vs. .9% placebo
se: erythema 5%
1x/day for seven days, remove w/alcohol and begin again
![Page 52: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/52.jpg)
Onychomycosis- systemic
Oral meds:
Terbinafine- 250 mg qd X 6 wks Fingernails;
X 12 wks Toenails
Itraconazole- 200 mg bid 1 wk/month
X 2-3 months Fingernails;
X 3-4 months Toenails
Fluconazole- 150-300 mg 1x/week x 6-9 months
Side effects: GI, Skin, H/A, LFT, Drugs
![Page 53: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/53.jpg)
Onychomycosis- oral meds
RCT-DB, PC- 72 week f/u 496 patients Continuous terbinafine vs. pulsed itraconazole No diff. SE’s
T3 T4 I8 I4MC 76% 81% 38% 49%CC 54% 60% 32% 32%
(BMJ, 4/99, 318: 1031-1035)
![Page 54: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/54.jpg)
Evidence-based reviews- Fungal
Pooled analysis trials comparing mycological cure rates
Continuous treatment with terbinafine (250 mg/d for 12 weeks) & continuous treatment with itraconazole (200 mg/d for 12 weeks)
Statistically significant difference in 1 year outcomes in favor of terbinafine (risk difference, -0.23 [95% confidence interval, -0.32 to -0.15]; number needed to treat, 5 [95% confidence interval, 4 to 8]).
(Crawford, Arch Dermatol, 2002)
![Page 55: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/55.jpg)
Evidence-based review- Fungal
Oral treatments for T. Pedis Twelve trials, 700 participants 2 trials comparing terbinafine and griseofulvin A pooled risk difference of 52% (95% confidence
intervals 33% to 71%) in favor of terbinafine's ability to cure infection
(The Cochrane Library, 2003, http://www.update software.com/abstracts/ab003584.htm)
![Page 56: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/56.jpg)
Summary
Do a KOH when possible or doubtful Avoid brand name combination
steroid/antifungal products Remember patient education strategies
![Page 57: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/57.jpg)
Pearls
T. capitis- overdiagnosed in adults/under in children; oral therapy needed
T. cruris- spares scrotum T. manus- often unilateral T. Pedis- highly variable presentation T. versicolor- oral therapy effective Onychomycosis- oral meds needed
![Page 58: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/58.jpg)
![Page 59: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/59.jpg)
What’s the diff dx?
How to dx? Use combo
meds? How to tx?
![Page 60: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/60.jpg)
Diff dx:» SCCa, Eczema, Tinea
How to dx: » KOH, KOH, KOH
Use combo meds: NO» wrong 30% » unclear length of time» more difficult for subsequent dx » $$$» potent steroids
Tx: Lidex 0.05% bid
![Page 61: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/61.jpg)
A few unknowns
![Page 62: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/62.jpg)
A few unknowns
![Page 63: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/63.jpg)
A few unknowns
![Page 64: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/64.jpg)
A few unknowns
![Page 65: Fungal Infections of the Skin and Nails](https://reader036.vdocuments.us/reader036/viewer/2022070407/5681432c550346895daf9c73/html5/thumbnails/65.jpg)
Thank You …….