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Fungal Infection of the Skin
Dr. Mohamad Nasr Lecturer Of Dermatology & Venereology
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Topics Covered
Tinea infections with special attention to scalp, feet and nails
Basic diagnostic techniques– KOH– Culture– Woods light
Differentials to consider. Basic Treatment Tinea Versicolor Candidiasis
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Dermatophytosis
“Ringworm" disease of the nails, hair, and/or stratum corneum of the skin caused by fungi called dermatophytes.
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Etiological agents
Microsporum - infections on skin and hair (not the cause of TINEA UNGUIUM)
Epidermophyton - infections on skin and nails (not the cause of TINEA CAPITIS)
Trichophyton - infections on skin, hair and nails.
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Clinical manifestations of ringworm
Infections named depending on location of infection.
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Tinea capitis; ringworm infection of the scalp. Tinea corporis; ringworm infection of the body
(smooth skin) Tinea cruris; ringworm infection of the groin. Tinea unguium; ringworm infection of the nails. Tinea barbae; ringworm infection of the beard. Tinea manuum; ringworm infection of the hand. Tinea pedis; ringworm infection of the foot (athlete's
foot).
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Tinea corporis - body ringworm
Skin lesion pink-red, scaly, annular patch with expanding border (active border).
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Tinea cruris - ringworm of the groin
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Tinea capitis - ringworm of the scalp
Types:1. Scally.
2. Black dot.
3. Favus.
4. Kerion.
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Scally type;
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Black dot type;
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Kerion;
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Favus;
caused by T. schoenleinii.
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Tinea Capitis Treatment
•Must treat hair follicle
•Topical not effective
•Systemic agents
•Griseofulvin for children ;12.5 mg/kg.
•Imidazoles, terbinafine.
•Steroids for inflamed lesions like Kerion.
•Treat until no visual evidence, culture (-)… plus 2 weeks
•Average of 6-8 weeks of treatment.
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Other oral anti-fungal for patients who do not tolerate or respond to Griseofulvin.
Terbinafine (Lamisil) 3 to 6mg/kg once a day for 2 to 4 weeks.
Fluconazol: 6mg/kg/day once daily for 6wk Itraconazole: 5mg/kg/day,once daily or divided
into two doses,for 2 to 4 weeks
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Tinea pedis - Athletes' foot infection
Between toes or toe webs - 4th and 5th toes are the most common.
Types;1. Interdigital type.2. Hyperkeratotic type.3. Vesiculobullous type.
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Tinea Pedis: Treatment
•Dry Feet
•Alternate shoes, Absorbent powders, Change socks
•Scale my be reduced with keratolytic
•Topicals and/or Systemics.
•Topical: terbinafine may be more effective than azoles. Steroids if inflamed.
•Systemic allyamines or azoles
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Tinea Manuum
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Onychomycosis
15-20% of those between 40-60 yrs. infected.
No Spontaneous remissions General Appearance:
– Typically begins at distal nail corner– Thickening and opacification of the nail plate– Nail bed hyperkeratosis – Onycholysis– Discoloration: white, yellow, brown– Edge of the nail itself becomes severely eroded.
Some or all nails may be infected
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Tinea unguium - ringworm of the nails
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Onychomycosis
Types:1. Distal Subungal
2. White superficial Chalky white patches
3. Proximal Subungal May indicate HIV infection
4. Total dystrophic
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Onychomycosis
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Onychomycosis with Onycholysis
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White Onychomycosis
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Candidaisis of nail
Paronychia
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Psoriasis
Middle of nail, oils spots, pitting.
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Treatment of Onychomycosis.
Topical Treatment:
• Can be effective for limited involvement and for prevention.
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Treatment of Onychomycosis
Oral therapy
•Effective. Relapse rate 15-20 % in one year.
•Lamisil 250mg. 6 weeks/12 weeks.
•Baseline labs and one month.
•CBC (neutropenia), Liver function.
•Itraconazole.
•Pulse dosing fingernails - (200 mg bid 1 wk q mo.) x 2
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Tinea Faciales
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Diagnostic Tests
KOH Preparations– A slide.– Scrape border of lesion.– Apply 1-2 drops of KOH 20% and heat gently– Examine at 40x– Look for hyphae
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Fungal Cultures
DTM (Dermatophyte Test Medium)– Yellow to red is (+).
Sabouraud’s agar Media
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Wood’s Light
– Tinea Capitis Blue green florescent with M. Canis. Not useful for Trichophyton (Most Common)
– Other Areas: Useful to diagnose as erythrasma (coral red/pink). Tinea versicolor may be pale yellow. Less helpful if patient recently bathed.
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Tinea Versicolor
Numerous, well-marginated, oval-to-round macules with a fine white scale when scraped.
Pigmentary alteration uniform in each individual.
– Red– Hypo pigmented– Hyperpigmented
Scattered over the trunk and neck. Seldom the face.
Pityrosporum orbicularis, M. furfur– Normal flora of skin
Asymptomatic.
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Tinea Versicolor
More apparent in the summer.
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Tinea Vesicolor
Hyperpigmented
Variety
Looks Like: intertrigo, erythrasma ….
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Tinea Versicolor - Differential
•Vitiligo
•Pityriasis Alba
•Pityriasis Rosea
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Vitiligo
White without scale.
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Pityriasis Alba
Frequently on face, KOH neg. Few lesions.
May have fine white scale.
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Pityriasis Rosea
•Papules or plaques with Collarette of scale, KOH (-), Woods light neg.
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Tinea Versicolor
Diagnosis:•Scrape lightly – fine white scale
•KOH Positive for short hyphae and spores (Spaghetti and meatballs)
•Woods Light – pale yellow white fluoresce.
•Culture rarely done.
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Tinea Vesicolor – Woods Light
Yellow White
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Tinea Versicolor Microscope
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Tinea Versicolor-Treatment
Topical; for limited involvement.
•Selenium Sulfide Shampoos: lather 10 minutes wash off x 7 days.
•Ketoconazole 2% shampoo: 5 minutes 1-3 days.
•Imidazoles topicals to body qd-bid for 2-4 wks.
•Terbinafine spray.
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Tinea Versicolor-Treatment
Oral; for extensive
•Itraconazole: 200 mg for 7days
•Fluconazole: 300 mg once
•Ketoconazole: 200 mg for 10 days
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Notes•Hypopigmentation resolves slowly
•No scale when scraped indicates cure.
•Sunlight helps restore pigment
•Prophylaxis before summer in some patients.
•Selenium shampoo’s
Tinea Versicolor-Treatment
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Candidiasis
•Candida Albicans
•Normal Flora
•Occurs in moist areas especially where skin touches.
•Presentation: primary lesion is a red pustule.
•Most Common: pustules dissect horizontally through the stratum corneum leaving a red, glistening denuded surface with long continuous border with satellite lesions.
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Candidiasis
•Immunosuppression of any type (disease, steroids, D.M. or Antibiotics).
•Diagnosis: History of predisposing factors and/or classic appearance of lesions at typical locations.
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Clinical picture;
1. Oral candidiasis; thrush & perleche.
2. Cutaneous candidiasis;– Intertrigo.– Erosio-interdigitalis blastomycetica.– Paronychia.
3. Genital candidiasis;
4. Systemic candidiasis;
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Thrush
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Angular cheilitis
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Intertrigo
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Intertrigo
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Erosio-interdigitalis blastomycetica
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Candidiasis
•KOH for pseudohyphae and spores
•May be impossible to tell visually from tinea.
•Woods Light
•Culture.
•Remember yeast part of normal flora.
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Treatment of Candidiasis
• Keep dry –powder, cotton ball between toes.
• Topical – azoles.
• Systemic – fluconazole; 150 mg once.
Itraconazole; 200 mg bid for 1 day
• Occasionally co-administration of a weak topical steroid may be helpful.
• Diaper rash
• Angular chelitis.
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