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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

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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.