fungal infections of the skin and nails

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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 [email protected] Fungal Infections of the Skin and Nails. Objectives - PowerPoint PPT Presentation

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  • Fungal Infections of the Skin and NailsAdam O. Goldstein, MD, MPHAssociate ProfessorDepartment of Family MedicineUniversity of North Carolina at Chapel [email protected]

  • Fungal Infections of the Skin and NailsObjectives1. To distinguish common fungal infections from similar appearing lesions; e.g. eczema2. Improved dx of fungal lesions with a KOH scraping3. Know at least 2 tx options for common fungal infections of the skin & nails4. Know common errors in fungal dx and tx5. Know when to suspect & how to dx ID reaction

  • Sorry but .

  • Superficial Fungal Infections4.1 million visits -82% nondermatologists3 types of fungi-dermatophytes: EpidermophytonTrichophyton Microsporum

    Named by locationSimilar treatments; Varied presentations

  • If they do this to food..

  • Superficial Fungal InfectionsCommon 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)

  • KOH

  • ID ReactionSevere inflammatory skin reactionImmunologically mediatedAppearance may be very different from original lesionFungal infections if severe enough may provoke ID reaction. If you do not think about it, you will not diagnose it.

  • ID Reaction

  • Tinea capitisTrichophyton or Microsporum speciesDisease of childrenExposure from other children or petsHighly variable presentation

  • T. capitisPrimary lesions: plaques, papules, pustules or nodulesSecondary lesions: scale, alopecia, erythema, exudate and edema

    Kerion: Severe T. capitis- inflamed, boggy nodule with hair loss

  • Kerion

  • T. capitisDiagnosisOverdiagnosed in adults, underdiagnosed in childrenDirect microscopic exam of hairs looking for hyphae/sporesWoods lamp: bright green fluorescence in hair shafts d/t Microsporum infection (< 20% time)Culture: If KOH is negative but strong clinical suspicion

  • T. capitisDifferential DiagnosisSeborrheic dermatitis- rare in children, KOH -Cellulitis- may coexist, KOH -Alopecia areata-discrete, nonscaling areas hair lossSyphilis- mothball eaten areas

  • The diagnosis please..

  • T. capitisTreatment Systemic therapy neededGriseofulvin 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

  • GriseofulvinMicrosize 250, 500 mg tabs, 125 mg/5 cc susp500-1000 mg/day adults15-20 mg/kg/day childrenSEs: photosensitivity, H/A, GI upset, hypersensitivity, leukopeniaActive only against dermatophytes, not yeasts

  • T. capitisPatient educationCompliance for 2 weeks beyond cure to prevent relapseLook for sources of infectionsClean contaminated objectsReassure caretakers that it may take 1 month for improvement

  • Tinea barbaeCharacteristicsInflammation in the beard/hairPseudofolliculitis Frequently failed antibioticsPositive S.Aureus culture does not rule out T. barbae

  • T. barbaeDiagnosisNodular, boggy lesions with exudateSinus tract formationScarring if untreatedKOH or culture may confirm

  • T. barbaeDifferential diagnosisBacterial folliculitisPseudofolliculitis barbaeContact dermatitisHerpesSyphilisAcneCandida

  • T. barbaeTreatmentGriseofulvin 0.5-1 g/dayItraconazole or terbinafine for resistant casesLocal care

  • Tinea corporisPapules or plaques with erythema and scaleLook for annular lesions with central clearingWell-demarcated edges

  • T. corporisDiagnosisKOH from leading edgePrior steroid use alters response/appearanceMajocchis granuloma: pluck hairs for hyphae

  • T. corporis vs. Majocchis granuloma

  • T. corporisDifferential diagnosisNummular eczema KOH negPityriasis rosea KOH neg, multiple papules/plaquesPsoriasis KOH neg, thick, silvery scalesGranuloma annulare KOH neg, no scaleLyme disease KOH neg, no scale

  • T. corporis: Differential diagnosis

  • The diagnosis please...Lichen simplex chronicusNummular eczema

  • T. corporisTreatmentAvoid Lotrisone type combos Topical agents for mild/moderate diseaseOral agents for extensive/resistant diseaseContinue topical medication 7-14 days beyond cure

  • Tinea crurisThrives in humid environmentsDiagnosis: Spares scrotum; Pruritus & burning cluesLook for feet as possible infection sourceKOH + hyphae

  • T.crurisDifferential Diagnosis: Candida Beefy red with poorly defined bordersIntertrigo KOH negative, irritant dermatitisErythrasma Asymmetric velvety patches, Neg KOHPsoriasis Thick silvery scales,Neg KOHSeb derm Borders less defined, distribution different, Neg KOH

  • T. crurisTreatmentTopical agents for 2-3 weeksMild topical steroid for inflammatory componentPruritus relief Look for infection source

  • T. crurisPatient educationUse topical meds 7-14 days beyond cureAvoid prolonged topical steroidsAvoid self-medicating prepsAvoid baths and tight fitting underwearUse mild soaps or soap substituteAntifungal powdersKeep area dry

  • Tinea manusDiagnosis: Often unilateral, but with bilateral feetMay have only scant scaling, vesiclesDifferential Diagnosis: Eczema, contact dermatitisTreatment: Topical agents

  • The diagnosis is ...

  • Tinea pedisDiagnosis: Extremely variable presentationBe aware of id reaction and bacterial infection

  • T. pedisDifferential Diagnosis: Eczema, Contact, Psoriasis, Keratolysis

    Treatment and Patient Education: Limited: Antifungal creams X 1-4 weeks; Severe: Oral therapyGriseofulvin 500 mg microsize bid X 4-8 weeksTerbinafine 250 mg/day X 2-6 weeks

  • The diagnosis is ..

  • Tinea VersicolorDiagnosis: macules, plaques; fine scale after scraping; KOH +

  • Tinea VersicolorTreatment: Limited disease: Topical agentsWidespread: Ketoconazole 200 mg X 2 one dose, repeat 1 week (Not griseofulvin)Prevention and Patient Education:Selenium sulfide 2.5% overnight 1X/month

  • CandidiasisDiagnosis: Beefy red lesions, satellite papules and pustulesDifferential Dx: Tinea, Intertrigo

    Treatment and Patient education : Topical antifungal creamsOral therapy for extensive (not Griseofulvin)Environmental: Zeasorb powder or BurowsMild topical steroids

  • The diagnosis is...

  • Onychomycosis

  • OnychomycosisWhy should we treat? (cosmetically disfiguring, painful, entry for cellulitis)Diff Dx: Psoriasis, Lichen Planus, TraumaDiagnosing vs. treating

  • Diagnosis?Culture?Treatment?

  • CaseWhich of the following, if any, is onychomycosis?

  • Onychomycosis- treatments8% 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

  • Onychomycosis- systemicOral meds:Terbinafine- 250 mg qd X 6 wks Fingernails; X 12 wks ToenailsItraconazole- 200 mg bid 1 wk/month X 2-3 months Fingernails; X 3-4 months ToenailsFluconazole- 150-300 mg 1x/week x 6-9 months

    Side effects: GI, Skin, H/A, LFT, Drugs

  • Onychomycosis- oral medsRCT-DB, PC-72 week f/u496 patientsContinuous terbinafine vs. pulsed itraconazoleNo diff. SEs T3 T4 I8 I4MC 76% 81% 38% 49%CC 54% 60% 32% 32%

    (BMJ, 4/99, 318: 1031-1035)

  • Pooled analysis trials comparing mycological cure ratesContinuous 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]). Evidence-based reviews- Fungal(Crawford, Arch Dermatol, 2002)

  • Evidence-based review- FungalOral treatments for T. PedisTwelve trials, 700 participants2 trials comparing terbinafine and griseofulvinA 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)

  • SummaryDo a KOH when possible or doubtfulAvoid brand name combination steroid/antifungal productsRemember patient education strategies

  • PearlsT. capitis- overdiagnosed in adults/under in children; oral therapy neededT. cruris- spares scrotumT. manus- often unilateralT. Pedis- highly variable presentationT. versicolor- oral therapy effectiveOnychomycosis- oral meds needed

  • Whats the diff dx?How to dx?Use combo meds?How to tx?

  • Diff dx:SCCa, Eczema, TineaHow to dx: KOH, KOH, KOHUse combo meds: NOwrong 30% unclear length of timemore difficult for subsequent dx $$$potent steroidsTx: Lidex 0.05% bid

  • A few unknowns

  • A few unknowns

  • A few unknowns

  • A few unknowns

  • Thank You .