24 CHEMIST+DRUGGIST 20.09.2014

CPD Zone Update

This module covers:● Types of fungi● How athlete’s foot is contracted and treatment options● Presenting symptoms and treatment for fungal nail infections● Causes of and self-care advice for fungal skin and groin infections● Preventing the spread of fungal scalp infections and oral and topical treatments

UPDATEModule 1719

September» Infections month

● Influenza September 6

● Antibiotic resistance September 13

● Fungal infections September 20

● Common parasites September 27*

*Online-only for Update and Update Plus subscribers

chemistanddruggist.co.uk/update

Steve Titmarsh

Fungal infection of the body can produce a wide range of diseases. Yeast infection, involving Candida species, for example, causes problems such as oral candidiasis, angular chelitis, skin fold infections (intertrigo) and nappy rash. Dermatophyte infections of the skin cause problems such as athlete’s foot and fungal nail infections. Systemic fungal infection tends to be more serious, resulting in conditions such as aspergillosis, cryptococcal meningitis and pneumocystis.1,2

This article focuses on fungal skin infections of the feet, scalp, nails, body and groin. The infecting organism is usually a dermatophyte or ringworm (tinea). There are three genera of dermatophyte: Trichophyton, Microsporum and Epidermophyton. Humans act as hosts in the case of anthropophilic dermatophytes – for example, Trichophyton rubrum – while animals host zoophilic dermatophytes such as Microsporum canis, which typically affects household pets.

Both types of fungi depend on their hosts and can survive only by passing from one host to another. Other dermatophytes, known as geophilic, are found in soil – for example, Microsporum fulvum. While anthropophilic organisms provoke minimal immune response in human skin, zoophilic or geophilic dermatophytes can provoke a more pronounced inflammatory reaction.3

Athlete’s footFungal foot infection affects between 15 and 25 per cent of the population at any one time. It is common among adolescents, but rarely seen before puberty.4

Athlete’s foot (or tinea pedis) is frequently contracted under warm, moist conditions when bare feet come into contact with skin scales from infected individuals such as in public swimming pools, communal showers and changing rooms.

Athlete’s foot has several forms: interdigital, moccasin and vesiculobullous. The interdigital

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Fungal skin infections

Swimming pools are a common breeding ground for athlete’s foot infections for those of all ages

CPD Zone Update

form is most common and is usually caused by Trichophyton rubrum, which also causes the moccasin form of the condition. It appears as white, cracked or macerated areas between toes and affected skin may also be red, scaly, flaky and dry.5 When the infection spreads to the sole and sides of the foot this is known as the moccasin form, and presents with a diffuse scaling pattern.

The third and least common type is known as vesiculobullous and is often caused by Trichophyton mentagrophytes.4 It appears mostly on the soles of the feet as inflammatory eruptions.4 The infection may rarely spread to the hands if they are not thoroughly washed after touching infected skin. So-called tinea manuum usually affects the palm of one hand, which can become dry, red and itchy.5

Treatment of mild infection is usually with a topical antifungal such as clotrimazole, miconazole, econazole, ketoconazole (not licensed for children), terbinafine (not licensed for children), tolnaftate or undecanoic acid.

They are usually applied to the affected area, including a margin of several centimetres of normal skin, once or twice daily for up to six weeks. Treatment should continue for one or two weeks after the visible rash has cleared.6 Any associated fungal nail infection (see below) should be treated at the same time to prevent re-infection. People with athlete’s foot should:4,5

● regularly wash feet and dry thoroughly, especially between the toes● not scratch affected areas● avoid going barefoot in public places● keep feet cool and dry● wear cotton socks● regularly change and wash socks● regularly wash towels and bedding● alternate their footwear, particularly running shoes and trainers, so that dry shoes can be worn at all times.

Patients whose diagnosis is uncertain, do not respond to topical antifungals, have extensive or severe infection, or who are immunocompromised should be referred to a dermatologist.4

Fungal nail infectionPeople with athlete’s foot may also suffer with fungal nail infection (onychomycosis), which

can involve all or part of the nail. Toenails are affected more often than fingernails. The infection develops slowly – the nail thickens and changes colour, and can become white, black, yellow or green;7 the nail plate distorts; and the nail bed and surrounding tissue may thicken.8

Fungal nail infection tends to affect older people, while children are rarely affected. Prevalence among people aged over 60 years old is thought to be as high as 30 per cent.8

Mild infection may not need treatment with medicines because self-care methods – such as not wearing shoes that make feet hot, keeping nails short, dry and clean and using one nail clipper for the infected nails and another for the normal ones – may be sufficient.9

After confirming which organism is causing the infection by analysis of nail clippings, oral antifungals (terbinafine or itraconazole) or antifungal nail paint containing amorolfine may be recommended. Oral therapy has been shown to be more effective than topical treatment.8

Children with fungal nail infection should be referred for specialist treatment, as should those who do not respond to primary care treatment or who are immunocompromised. People whose nails are damaged by footwear or who have deformed nails that damage adjacent toes should see a podiatrist.10

Fungal skin and groin infectionFungal skin or groin infections are more common among men than women and can be caught by contact with an infected person or animal (common examples include dogs, cats, guinea pigs and cattle) or with items contaminated with the fungus (for example, clothes, bed linen or towels). Sometimes contact with soil can result in infection, but this is rare.

Fungal infection of the body – also known as ringworm or tinea corporis – is often caused by Trichophyton rubrum, which can also cause groin infection (tinea cruris), as well as Trichophyton mentagrophytes and Epidermophyton floccosum.12 The infection is mainly seen in adolescent and young men. Women who are overweight or wear tight clothes may also be affected.

Patients with tinea corporis typically have one or more red or pink, flat or slightly raised patches of skin that grow larger into ring-

Topical treatment for fungal nail infections is more effective than oral therapy oral therapy

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True or false?

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Interdigital athlete’s foot (tinea pedis) Fungal nail infection (onychomycosis)

26 CHEMIST+DRUGGIST 20.09.2014

CPD Zone Update

EXPERT Q&AWant to know more? Our infections expert is on hand to answer any further questions you may have on this month’s topic. Email your queries to: asktheexpert@updateplus.co.uk

shaped lesions with red, scaly borders and a clear centre.10

Infection of the groin is most frequently seen, affecting skin folds of the inner thighs around the groin area. Lesions are commonly red to red-brown, flat or slightly raised plaques with active borders (pustules or vesicles). They often itch, and in some cases there is uniform scale without central clearing.10

Treatment for mild, non-extensive infection includes topical clotrimazole, econazole or miconazole. A mild topical corticosteroid such as hydrocortisone 1 per cent can be recommended for people who have particularly inflamed skin, but should not be used for more than one week.10

As with other fungal infections, personal hygiene and cleanliness are important in managing the condition and restricting or preventing its spread. Advise people to:10 ● wash clothes and bed linen frequently to eradicate the fungus● wash affected skin every day and dry thoroughly afterwards, particularly in the skin folds● not share towels and wash them frequently● wear loose-fitting cotton clothes, or clothes made of a material that is designed to keep moisture away from the skin.

People who do not respond to treatment, have recurrent infection, severe or extensive infection or who are immunocompromised should be referred to a specialist.

Fungal infection of the scalpTinea capitis – fungal infection involving the scalp – is mainly caused by Trichophyton tonsurans in cities and by Microsporum canis in rural areas. The infection can be spread among family members and school children via spores or infected hairs, which can be transmitted by person-to-person contact or through the air. Some children and adults can be unwitting carriers, showing no signs or symptoms.11

Typical symptoms include scaling of the scalp, patchy irregular hair loss, itching and swollen lymph nodes. Some people have a more

severe inflammatory reaction, with symptoms including erythema, pustules and crusting.

To help the prevent re-infection or transmission of infection to others, individuals should be advised to throw away, where possible, items such as hats, combs, pillows, blankets and scissors, which can transmit fungal spores.

Alternatively, where possible, clean items with bleach. Towels should be washed regularly and not shared with other people. If children show signs of scaling or hair loss they should be referred to their doctor.11

Ideally, a positive microscopy or positive culture of skin scrapings should be obtained before starting treatment.

Oral treatment is preferred for adults. Griseofulvin is recommended for Microsporum infections. Treatment should be given for four to eight weeks (eight to 12 weeks in resistant cases) and continued for at least two weeks after all signs of infection have gone.

The drug should be taken after a high-fat meal for increased absorption and to minimise the risk of gastrointestinal side effects. Terbinafine, although not licensed for this specific indication, is recommended for Trichophyton tonsurans infection. Treatment is usually continued for four weeks.11

In adults, selenium sulphide or ketoconazole shampoo – or another topical antifungal cream such as an imidazole or terbinafine – can be used twice a week for the first two weeks to reduce the chances of infecting other people.

Patients should be reviewed four to eight weeks after treatment finishes to confirm a clinical cure.11

Patients should be referred for specialist care in cases where:11 ● they have an abscess – for example, a pustular boggy mass on the scalp, known as a kerion● the diagnosis is uncertain or guidance on treatment is needed● there is no response to primary care management● the infection is severe or extensive, or scarring is present

● the infection is recurrent● the person is immunocompromised.

References1. Centres for Disease Control and Prevention. Fungal diseases. www.cdc.gov/fungal/diseases/index.html2. Medicines Complete www.medicinescomplete.com3. DermNet NZ. Mycology of dermatophyte infections. www.dermnetnz.org/fungal/mycology.html4. NICE Clinical Knowledge Summaries. Fungal skin infection – foot. cks.nice.org.uk/fungal-skin-infection-foot.5. NHS Choices. Athlete’s foot. www.nhs.uk/Conditions/Athletes-foot/Pages/Symptoms.aspx6. DermNet NZ. Topical antifungal medications. www.dermnetnz.org/treatments/topical-antifungal.html7. NHS Choices. Fungal nail infection. www.nhs.uk/Conditions/Fungal-nail-infection/Pages/Symptoms.aspx 8. NICE Clinical Knowledge Summaries. Fungal nail infection. cks.nice.org.uk/fungal-nail-infection9. British Association of Dermatologists. Fungal infection of the nails. www.bad.org.uk/ResourceListing.aspx?sitesectionid=159&itemid=391&q=Fungal%20infections%20of%20the%20nails%20-%20printable%20version#.VAR5iWRdVIk10. NICE Clinical Knowledge Summaries. Fungal skin infection – body and groin. http://cks.nice.org.uk/fungal-skin-infection-body-and-groin 11. NICE Clinical Knowledge Summaries. Fungal skin infection – scalp. cks.nice.org.uk/fungal-skin-infection-scalp

Fungal ringworm infection (tinea corporis) Fungal scalp infection (tinea capitis)

CPD Zone Update

1. Zoophilic or geophilic dermatophytes can provoke a more pronounced inflammatory reaction in humans than anthropophilic organisms. True or false?

2. The vesiculobullous form of athlete’s foot usually appears as white, cracked or macerated areas between toes. True or false?

3. Tinea manuum usually affects the palm of one hand. True or false?

4. Topical ketoconazole and terbinafine are not licensed for use in children. True or false?

5. Fingernails are more likely to be affected by fungal infections than toenails. True or false?

6. Fungal nail infections are more prevalent in people aged over 60 years. True or false?

7. Topical treatment of fungal nail infections has been shown to be more effective than oral therapy. True or false?

8. Children with a fungal nail infection should be referred for specialist treatment. True or false?

9. Fungal infections of the body are mainly seen in young, adolescent men. True or false?

10. Oral treatment for fungal infection with griseofulvin is usually given for two weeks only. True or false?

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Reflect What are the three different forms of athlete’s foot? How are fungal nail infections treated? Which organism causes tinea capitis?

Plan This article provides information for pharmacists about common fungal infections of the skin. The symptoms and treatments for fungal infections involving the feet (athletes’ foot), nails, skin (tinea corporis, tinea cruris) and scalp (tinea capitis) are discussed, as well aswhen to refer.

Act Read the Update article and the suggested reading (below), then take the 5 Minute Test (above). Update and Update Plus subscribers can then access answers and a pre-filled CPD logsheet at chemistanddruggist.co.uk/mycpd.

Find out more about fungal nail infection on the Patient.co.uk website at tinyurl.com/fungal3

Read more about athlete’s foot and its symptoms, treatment and prevention on the NHS Choices website at tinyurl.com/fungal2

Find out more about fungal infections of the skin on the body from the NHS Choices website at tinyurl.com/fungal4

Read more about fungal infection of the scalp on the Patient.co.uk website at tinyurl.com/fungal5

Review the products for fungal skin infections kept in your pharmacy. Which ones would you recommend? Make sure your counter staff are aware of your choices and know when to refer.

Evaluate Are you now confident in your knowledge of fungal skin infections? Could you identify them and advise patients about treatment and prevention?

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Update plus-side ad-right(2) sept 6.indd 1 01/09/2014 11:33