Management of

Common Common

Fungal Skin Infections

• Superficial fungal infections of

the skin are one of the most

common dermatologic

conditions seen in clinical conditions seen in clinical

practice.

Fungi: Common Groups

1. Dermatophytes: Superficial Ring

worm type

2. Candida Albacans: Yeast infection2. 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.Subcutaneous3.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 • 20 Spp. of dermatophytes cause ringworm.

3. Subcutaneous mycoses

-Subcutaneous infections, over 35 spp.

Produce chronic inflammatory disease

of subcutaneous tissue & lymphatics, 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- 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▪ 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. Aspergillosis2. Aspergillosis

3. Cryptococcosis

4. Zygomycosis/mucormycosis

5. Pneumocystis carinii

Superficial Fungal

Infections

• Tinea infections• Tinea infections

TINEA Infection

• T.Corporis- ringworm of body

• T.Cruris- groin• 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)• Annular patch (ring shaped)

• Well defined edge

• Scaling more obvious at

edges(central clearing)

Tinea Corporis

Tinea corporis – body ringworm

Tinea corporis

Tinea Corporis Tinea of the face

Psoriasis Tinea corporis(Scaly lesion)Psoriasis (for differential diagnosis)

Tinea corporis(Scaly lesion)

TineaManum (hand) Tinea Corporis

• Often assoc with T.pedis

• “Jock itch”

TINEA CRURIS (groin)

• “Jock itch”

• Tight hot sweaty groin e.g. athletes, obese

• Infection of groin, genitalia, perinium

Tinea Cruris – Jock Itch

Tinea Pedis –

Athlete’s Foot Infection

Tinea Pedis�Clinical features

• Dermatitis

• Peeling • Peeling

• Maceration

• Fissuring

Sites

Toe clefts

Tinea Unguium – Nail Infection

Tinea Unguium (nail)

1. Disto-lateral

subungual

onychomycosis

1

onychomycosis

2. Superficial white

onychomycosis

3. Total dystrophic

onychomycosis

2

3

Regimes-Tinea Unguium

• TERBINAFINE

– Terbinafine250mg od

• ITRACONAZOLE• ITRACONAZOLE

– Pulse rx Itraconazole - 1wk/mth 200mg bid

– Itraconazole 200mg od

• FLUCANAZOLE

– Fluconazole 150mg once weekly

T.Pedis

TINEA CAPITIS - KERION

Ringworm of the scalp

TINEA CAPITIS – Black dot

Tinea Capitis

Tinea Capitis

Gray Patch

Rx-Tinea Capitis

• MUST use oral Rx- prolonged course

–Griseofulvin-20mg/kg/od x 6-8/52 –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 InfectionsOther Fungal Infections

Tinea Manuum

�Dry hyperkeratotic

Palmer aspect

Dorsal aspect

Tinea Barbae

Tinea Faciei

• Infection of the

skin of the face

excluded excluded

moustache &beard

areas

Peri-oral dermatophytosis

Investigation:

- Microscopy of scrapings

KOH preparation and looking 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 prepstopical 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

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

For Systemic Fungal Infections

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-OPDCOMMON FUNGAL PROBLEMS: All types

Rx: prescribed:

1. Hygiene teaching.

2. Antifungal: 2. Antifungal:

a. Topical: Ketaconazole, Clotrimazole,

Butrinazole

b. Oral: Fluconazole, Ketaconazole, itrazole

Thank YouThank You

7. Yeasts• Pityrosporum.

• Candida.

• Ordinarily commensals.

• Can become pathogens under favourable conditions.

Pityriasis Versicolor

• Asymptomatic

scaly maculeshypopigmented

• Chest, back, face

P.Versicolor• Hyperpigmented

Like Dubi

Pityriasis Versicolor

8. Tinea Versicolor

(In Head)(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- sharp border

- itching, worsens with heating and

sweating

� Tx

- Topical antifungal medications

Management• Many Rx

• No Rx eradicates yeast permanently

• NONSPECIFIC

• Keratolytics • Keratolytics

– whitfield onit, sulphur

• Antiseptics

– selenium sulphide, Na thiosulphate

Antifungal Rx

Azoles-oral/topical

• Ketoconazole 200mg od x7

• Itraconazole 200mg od x 7• 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�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• Chronic Paronychia - nail fold infection

• Vaginitis/balanitis

Risk Factors for Candidiasis:

▪ Post-operative status

▪ Cytotoxic cancer chemotherapy

▪ Antibiotic therapy▪ Antibiotic therapy

▪ Burns

▪ Drug abuse

▪ GI damage

Candidal Intertrigo

• Moist folds

• Erythematous patch • 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 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 • 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)• 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-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 • 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 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 effective than griseofulvin. Once-weekly

dosing with fluconazole is another option,

especially in noncompliant patients.

• Personal hygiene (foot hygiene) is highly

advised.

Thank YouThank You