fungal infectionsacademic.sun.ac.za/stellmed/coursematerial/annual gp...t capitis • hair loss -...
TRANSCRIPT
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Fungal infections
Dr. W.I. Visser / KannenbergDivision of DermatologyDepartment of Medicine
Faculty of Health SciencesUniversity of Stellenbosch
Tygerberg Hospital
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Objectives
1. Dermatophyte infections
2. Candida infection
3. Malassezia infections
Clinical picture & Treatment
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Fungal skin infections
dermatophytes non-dermatophytes
• Yeast-like fungus – Candida albicans
• Molds
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KOH
• Dermatophyte
septate hyphae
• Candida
round or oval cells
pseudohyphae
septate hyphae
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Candida
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Dermatophyte
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If it scales scrape it!
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Terms
• ‘ringworm’
• ‘tinea’
• grow only in keratin
dermatophyte
infection
stratum corneum
hair
nail
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DERMATOPHYTE INFECTION
Microsporum canis
Trichophyton violaceum
Epidermophyton floccosum
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T. capitis
T. barbae
T. corporis
T. cruris
T. faciei
T. manuum
T. pedis
T. unguium
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DERMATOPHYTE INFECTION
OF THE SCALP
• mostly childhood
• sebum contains fungistatic fatty acids
• Trichophyton violaceum
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T capitis
• HAIR LOSS - patchy
• grey patch
• yellow patch (= impetigo)
• alopecia areata – like
• black dot type
• seborrheic dermatitis – like
• kerion (abscess-like) [antibiotics / surgery]
• favus
• pustular
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Favus
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Kerion
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Moth eaten
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Grey patch
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Black dot
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Alopecia areata-like
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IMPETIGO OF SCALP
primary impetigo vs. secondary impetigo
• head lice
• dermatophyte infection
• scabies
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DERMATOPHYTE INFECTION
OF THE
FACE AND BEARD
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T faciale
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T barbae
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DERMATOPHYTE INFECTION
OF THE
BODY
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T corporis
• annular lesions with active border, red and
scaly, central clearance
• adults : from feet
• child : from scalp
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T corporis
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Differential diagnosis
• Dermatitis
• Psoriasis
• Dermatophyte
• Medication
• Syphilis
• T-cell lymphoma
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DERMATOPHYTE INFECTION
OF THE
GROIN AREA
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T cruris
• men > women
• annular lesions with active border, red
and scaly
• central clearance
• look for DF infection of feet / nails
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T cruris
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DERMATOPHYTE INFECTION
OF THE
HAND
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T manuum
• usually unilateral
• red & scaly
• vesicopustular
• annular lesions with active border, red and scaly, central clearance
• Source : feet
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T manuum
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DERMATOPHYTE INFECTION
OF THE NAILS
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Tinea unguium
• toenails > fingernails
• especially adults
• aspecially great toenail
• thickened
• discoloured : yellowish / white
• subungal hyperkeratosis
• onycholysis
• paronychia
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T unguium
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DERMATOPHYTE INFECTION
OF THE
FOOT
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T pedis
• between toe’s (athlete’s foot) [swimming pool / shower]
• annular lesions with active border, red and scaly,
• central clearance
• vesicopustular
• red and scaly (mocassin)
• Diabetic patients at risk
• TWO FEET, ONE HAND!
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T pedis
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WOOD’S LIGHT
• Microsporum canis
• yellow-green
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M. canis
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TINEA INCOGNITO
• dermatophyte infection
• topical steroids
• altered appearance
• erythema with scaling and pustules
• no active border!
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T incognito
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‘IDE’ REACTIONS
• dermatophyte infection (athlete’s foot)
• reaction at a distance
• vesicular, papular
• immunological
• no fungi
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Id reaction
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Learning point
If your patients’s “asymmerical eczema” is
spreading despite local steroids
– think of a dermatophyte infection
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DIAGNOSIS
• clinical
• KOH and microscopy
• culture
• skin biopsy
• therapeutic trial
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Scalpel blade
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Scalpel blade
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KOH
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Glass slide
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Microscope
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KOH microscopy
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Treatment
localized infection
• topical imidazole (eg. clotrimazole)
- fungistatic
• topical allylamine (eg. terbinafine)
- fungicidal
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Treatment
Systemic treatment for dermatophyte
infection of the scalp, onychomycosis of
many nails, and, widespread infection
elsewhere (eg. body)
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TREATMENT
• scalpGriseofulvin 10 – 20mg/kg with a meal for 6 weeks
• many nailsterbinafine (Lamisil)itraconazole (Sporanox)fingernails : 6 weekstoenails : 8 - 12 weeks
• all other widespread infection
itraconazole (Sporanox)terbinafine (Lamisil)griseofulvin
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Treatment
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MYCETOMA
• Direct inoculation
• Soil fungi
• Deep infection
• Abscesses and draining sinuses
• GRAINS/ GRANULES
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Mycetoma (Madura foot)
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Treatment
• Refer
• Surgery
• Systemic therapy
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Onychomycosis
• Encompasses all fungal infections of the
nail – dermatophytes/non-dermatophytes
• (nail dystrophy presentation)
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CANDIDA INFECTIONS
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Intertriginous candidiasis
of major flexures
Candida granuloma of
Scalp (rare)
Oral candidiasis
Interdigital candidiasis
Chronic paronychia and
nail plate
candidiasis
Genital candidiasis
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Candida albicans
• topical steroids
• systemic steroids
• immunity (HIV / AIDS, malignancy, CT)
• broad-spectrum antibiotics
• DM
• warmth, friction & moisture
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CandidaORAL MUCOSA
• erythema & white curd-like plaques
ANGULAR CHEILITIS (hoekstomatitis)(perlèche)
• age
• ill-fitting dentures
• Staphylococcus aureus
CHRONIC PARONYCHIA
• water immersionhousewivesbarstafffloristsfishmongers
• erythema, edema & nail dystrophy
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Chronic Paronychia
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BALANITIS / VULVOVAGINITIS
• poor hygiene
• pregnancy, OCP
• erythema
• small white patches
• erosions
INTERTRIGO
• = intertriginous areasincluding abdominal fat apron
• obesitypoor hygienered & scaly‘satellite’ pustules
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DIAGNOSIS
• clinical
• KOH and microscopy
• culture
• skin biopsy
• therapeutic trial
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TREATMENT
• nystatin (Mycostatin®)
• amphotericin B (Fungizone®)
• topical imidazole
• topical allylamine
• Lamisil® / Sporanox® po
• griseofulvin : effective Θ
• PVC / latex gloves with cotton lining
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Learning points
• Alwys check the urine for sugar.
• Remember that griseofulvin has no action
against Candida.
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PITYRIASIS VERSICOLOR
• Pityrosporum ovale (Malassezia furfur)
• young adults
• tropical climates
• macules with fine scaling
• hypopigmented
• hyperpigmented
• trunk and upper arms
• asymptomatic / cosmetic
• KOH & microscopy : “meatballs & spaghetti”
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P versicolor
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P versicolor
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P versicolor
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“meatballs & spaghetti”
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TREATMENT• selenium sulphide shampoo (Selsun®)
• Ketoconazole shampoo (Niz® shampoo)
• topical imidazole
• ketoconazole (Nizoral®)
400mg / day x 2 days
• Sporanox®
400mg stat
or 200mg / day x 7 days
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Important!
• residual hypopigmentation
1 – 2 years to repigment
• recurrence common
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Learning points
• This is not a dermatophyte infection, do
not try griseofulvin or terbinafine.
• Patients think the treatment has not
worked if their pale patches do not
disappear straight away
- Warn them about this in advance.
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Cryptococcus
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Histoplasmosis
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Sporotrichosis
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What must you know
• Dermatophyte infections
• Candida
• Malassezia
• Know about systemic fungi can effect skin
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Test
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